Document filename: Maternity Services Data Set User Guidance.docx
Directorate / Programme
HSCIC Information
Services
Project
Maternity and Children’s
Data Set Implementation
www.ic.nhs.uk/maternityandchildren/maternity
Document Reference
Project Manager
Jane Gregson
Status
Final
Owner
Netta Hollings
Version
V2.1
Author
Nicholas Richman
Version issue date
25/03/2013
Maternity Services Data Set
User Guidance
Copyright ©2013 Health and Social Care Information Centre
Maternity Services Data Set User Guidance
V2.1
25/03/2013
Document Management
Revision History
Version
Date
Summary of Changes
1.0
22/12/2010
Submitted to ISB for Full Standard Submission.
1.1
11/01/2011
Changes to reflect internal review.
1.2
25/03/2011
Changes to reflect external testing of User Guidance.
1.3
25/05/2011
Updated to reflect changes in implementation timescale. Minor
amendments and updates
1.4
24/10/2012
Major changes to reflect current position of project. This document is
brought into line with CAMHS User Guidance in style and content.
1.5
28/02/2013
Changes to reflect the revised output specification.
2.0
20/03/2013
Converted to new HSCIC document format and final amendments
2.1
25/03/2013
Minor changes following ISB review
Reviewers
This document must be reviewed by the following people:
Reviewer name
Title / Responsibility
Date
Version
Netta Hollings
Programme Manager,
HSCIC
20/03/2013
V2.0
Nicholas Richman
Service Development
Manager, HSCIC
20/03/2013
V2.1
Approved by
This document must be approved by the following people:
Name
Netta Hollings
Page 2 of 163
Signature
Title
Date
Version
Programme Manager,
HSCIC
20/03/2013
V2.0
Copyright ©2013 Health and Social Care Information Centre
Maternity Services Data Set User Guidance
V2.1
25/03/2013
Abbreviations
Abbreviation
BAPM
What it stands for
British Association of Perinatal Medicine
BMI
Body Mass Index
CAMHS
Child and Adolescent Mental Health Services
CCG
Care Commissioning Group
CDS
Commissioning Data Sets
CF
Cystic Fibrosis
ChiMat
Child and Maternal health Observatory
CHT
Congenital Hypothyroidism
CMACE
Centre for Maternal and Child Health Enquiries
CPA
Care Programme Approach
CQC
Care Quality Commission
CRL
Crown Rump Length
CYPHS
Children’s and Young People’s Health Services
DDA
Disability Discrimination Act
DFES
Department for Education and Skills
DH
Department of Health
DSCN
Data Set Change Notice
DVT
Deep Vein Thrombosis
e-GIF
e- Government Interoperability Framework
ECC
Ethics and Confidentiality Committee
ERG
Expert Reference Group
EPR
Electronic Patient Record
eSP
e-Screener Plus
FASP
Fetal Anomaly Screening Programme
FL
Femur Length
FSE
Fetal Scalp Electrode
GMP
General Medical Practitioner
GP
General Practitioner
HC
Head Circumference
HELLP
Haemolytic anaemia, Elevated Liver enzymes and Low Platelet count
ICD-10
International Classification of Diseases - 10
ISN
Information Standards Notice
ISB
Information Standards Board for Health and Social Care (ISB)
IT
Information Technology
LFT
Liver Function Test
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MCADD
Medium Chain Acyl-CoA Dehydrogenase Deficiency
MCWP
Maternity Care Working Party
MERG
Maternity Expert Reference Group
MHMDS
Mental Health Minimum Data Set
MSDS
Maternity Services Secondary Uses Data Set
NCCMDS
Neonatal Critical Care Minimum Data Set
NDS
National Data Sets Service
NHSCB
NHS Commissioning Board
NHS CfH
NHS Connecting for Health
NICE
National Institute for Health and Clinical Excellence
NICU
Neonatal Intensive Care Unit
NIGB
National Information Governance Board for Health and Social Care
NIRS
NHS Information Reporting Services
NNU
Neonatal Unit
NPSA
National Patient Safety Agency
NSF
National Service Framework
NT
Nuchal Translucency
NTD
Neural Tube Defect
OPCS
Office of Population Censuses and Survey
PAS
Patient Administration System
PE
Pulmonary Embolism
PKU
Phenylketonuria
PPH
Postpartum Haemorrhage
PSA
Public Service Agreement
RCOG
Royal College of Obstetricians and Gynaecologists
RCM
Royal College of Midwives
RCPCH
Royal College of Paediatrics and Child Health
RCPSYCH
Royal College of Psychiatrists
ROCR
Review of Central Returns
SCD
Sickle Cell Disease
SOA
Super Output Area
STI
Sexually Transmitted Infection
TZD
Time Zone Designator
UK NSC
UK National Screening Committee
WHO
World Health Organisation
Glossary of Non-Clinical Terms
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Maternity Services Data Set User Guidance
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25/03/2013
The glossary of non-clinical terms is for use within the Maternity Services Secondary Uses Data Set.
Term
What it stands for
Acute Trust
An NHS organisation responsible for providing a group of healthcare
services. An acute Trust provides hospital services (but not mental health
hospital services which are provided by a mental health Trust).
Aggregate data set
A set of data items (i.e. a data set) that captures data in aggregate form.
Each record within the data set pertains to a specific form of grouping.
Anonymisation
A method applied to patient identifiable data items to protect the identity of
individuals. Under Anonymisation, patient identifiable data items are:


randomly encrypted and no keys retained, or
completely removed
Anonymised data cannot be linked with other data sets for the same
individual, nor can it be reversed and the identity of the individual ever
determined.
Note – anonymisation is different from pseudonymisation
Central Data
Warehouse
The repository of data relating to the Maternity and Children’s Data Sets in
general and the MSDS data set in particular.
Clinical Data Set
A set of standardised data items that defines “what should be captured” by
clinical IT systems (healthcare systems).
Clinician
A qualified healthcare professional providing patient care. e.g. Midwife,
Obstetrician, Paediatrician, General Practitioner, Physiotherapist,
Ultrasonographer.
Contracted Service
Provider
Service provider responsible for developing and maintaining the central
data warehouse for the MSDS. This will be as per the contractual
agreement.
Data item
A single component of a data group that holds one piece of information
relating to an event or episode.
Data Group
A collection of data items that describe a distinct event or episode
Data Set
The full collection of data groups. See “output data set”.
Data Set Output
Specification
A specification that fully defines the data items and structure of the output
data set.
Data Submission File One file related to the MSDS that data providers submit to the central data
warehouse. A data submission consists of an XML file containing the data
for one or a number of reporting periods in the format provided by the
HSCIC.
Data submission
framework
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The process by which the data set is submitted by data providers to the
central data warehouse.
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Maternity Services Data Set User Guidance
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25/03/2013
Term
What it stands for
Derived
A data item populated at the central data warehouse as part of postdeadline processing. The derived data item is based on the manipulation
of the ‘source’ data items using mathematical, logical or other types of
transformation process, or by using source data to derive further data from
national look-up tables.
External data
collection system
A system (other than the central data warehouse) to which data providers
may submit data. The external data collection system may then submit
data to the central data warehouse on behalf of those data providers.
Flow
Submission of a file/data from a data provider or an external data
collection system to the central data warehouse.
Full Data Set
The full data set defined by the early part of the MCDS project, a sub-set
of which is included in the data set output specification.
Group
See “Data Group”
Information Standard An information standard is a formal document approved and issued by the
Information Standards Board (ISB). It defines technical criteria, content,
methods, processes and practices for mandatory implementation across
health and social care in England.
Information
Standards Board for
Health and Social
Care (ISB)
The board established in England for the governance and approval of
information standards for health and social care.
Information
Standards Notice
(ISN)
A notice of an Information Standard approved by the Information
Standards Board. When a health and social care organisation in England
receives an ISN they will ensure that they and their contractors comply
with the standard in a reasonable time (such time is defined within the
ISN). An ISN was previously known as a Data Set Change Notice (DSCN).
Last Good File
The most recent collection of valid records submitted by a data provider
for a reporting period.
Maternity and
Children’s Data Set
(MCDS)
A group of patient-level data sets that consist of:



N3
Maternity Services Secondary Uses Data Set (MSDS)
Children’s and Young People’s Health Services (CYPHS)
Secondary Uses Data Set
Child and Adolescent Mental Health Services (CAMHS) Secondary
Uses Data Set
The NHS national broadband network linking hospitals, medical centres
and General Practitioners in England and Scotland.
http://www.n3.nhs.uk/
National Code
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National Code definitions, within the Data Set Output Specification, list the
valid codes (and their descriptions) that a particular data item may have
within the scope of the data set.
Copyright ©2013 Health and Social Care Information Centre
Maternity Services Data Set User Guidance
V2.1
25/03/2013
Term
What it stands for
National data set
An ISB approved data set.
National Information
Governance Board
(NIGB) for Health and
Social Care
The NIGB is an independent statutory body established to promote,
improve and monitor information governance in health and adult social
care. From 1 April 2013, the NIGB's functions for monitoring and
improving information governance practice will transfer to the Care Quality
Commission, which is establishing a National Information Governance
Committee to oversee this work.
http://www.nigb.nhs.uk/
Null
A data item with no value (i.e. blank) and therefore, has no meaning. This
is different from a value of 0, since 0 is an actual value.
Output Data Set
A set of data items that data providers need to output/extract from local
systems and submit to the central data warehouse. Data providers have
the flexibility of adopting any local data collection process and system they
see fit, so long as the system can output data as per the output data set.
It is not necessary for clinical and operational systems to replicate the
output data set as it is not a definition of a clinical data set.
Output Data Set
Specification
See ‘Data Set Output Specification’.
Patient-Level data set A collection of data items (i.e. a data set) that captures data at individual
patient level. Each record within the data set pertains to only one patient.
Depending on the data items within the data set, the data may be
presented in identifiable or unidentifiable form.
Phase-1 Data Set
Data items to be implemented across the NHS via the Maternity Services
Secondary Uses Data Set (MSDS) Information Standard. The Phase-1
Data Set is a subset of the Full Data Set.
Post-deadline
Processing
The processing undertaken at the close of a submission window by the
central data warehouse.
Pre-deadline
Processing
The processing carried out immediately on a submitted file to validate the
file as a whole, extract the records that are (or may be) for the particular
reporting period, and validate those records.
Pseudonymisation
A method applied to identifiable data items to protect the identity of
individuals. Under pseudonymisation, a standard encryption key is used
to encode patient identifiable data items so that data linkages within and
outside the data set, for the same individual, is feasible. Because the
encryption key is retained by a single “Data Controller”, there is also the
potential to reverse the process (decode) and expose the identity of the
individual. The encryption key is only decoded for specific purposes, as
agreed with the Ethics and Confidentiality Committee (e.g.: migration of
data into another platform or enabling linkages to other data sets)
Note – Pseudonymisation is different from Anonymisation.
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Term
What it stands for
Reference Data Set
A data set outside the scope of the Maternity Services Secondary
Services Data Set (MSDS), but developed and published as a guide for
local development purposes only. In conjunction with the MSDS, the
Reference Data Set provides a comprehensive secondary uses data set
for maternity services. The Reference Data Set has not been approved as
a national data standard for by ISB nor does the central data warehouse
provide any storage capacity for the Reference Data Set.
Screening
A public health service in which members of a defined population, who do
not necessarily perceive they are at risk of, or are already affected by a
disease or its complications, are asked a question or offered a test, to
identify those individuals who are more likely to be helped than harmed by
further tests or treatment to reduce the risk of a disease or its
complications.
Secondary uses
Reusing clinical and operational data for purposes other than direct patient
care. For example, national reporting.
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Glossary of Clinical Terms
The glossary of clinical terms is for use within the Maternity Services Secondary Uses Data Set.
Term
What it stands for
Acute blood loss
Hypovolaemic shock requiring emergency volume replacement at birth.
Acute fetal
compromise
Immediate threat to life of fetus.
Amniotic Fluid
Embolism
An embolism is the mechanism of what occurs following the lodging of an
embolus (a detached mass at a site far from its origin). This usually occurs
within a narrow capillary vessel of an arterial bed which then causes a
blockage. An amniotic fluid embolism, occurs when amniotic fluid enters
the mothers bloodstream.
Antenatal
Following conception and before start of labour.
Antepartum
Following conception and before start of labour.
Antepartum
haemorrhage
Bleeding from the genital tract after the 24th week of pregnancy until the
birth of the baby.1
Birth trauma to the
newborn
Any bruising, haematoma, laceration, fracture or other injury to the baby,
as sustained during birth.
Booking Appointment The appointment where the mother enters the maternity care pathway.
Characterised by information giving and detailed history taking to help the
mother choose the most appropriate antenatal care pathway.
Includes measurement of height, weight, blood pressure and blood tests
for determining blood group, rubella status and haemoglobin level.
Blood and urine samples for screening may also be taken at booking after
the mother has been well informed and has given her consent.2
Caesarean section
An operation to deliver the baby by cutting through the wall of the
abdomen and the uterus. It may be done as a planned (elective) or an
emergency procedure.3
Cervical trauma
Partial disruption of the cervix of the uterus.
Cord prolapse
The descent of the umbilical cord through the cervix alongside (occult) or
past the presenting part (overt) in the presence of ruptured membranes.4
1
Oxford concise colour medical dictionary, New 3rd edition, Oxford University Press, 2002
2
England. NICE (Corrected Jun 2008) CG62 Antenatal Care: Full Guideline, London: RCOG Press, pp. xvi
[http://www.nice.org.uk/nicemedia/live/11837/36275/36275.pdf]
3
RCOG, Medical terms explained, Caesarean section [http://www.rcog.org.uk/womens-health/patient-information/medicalterms-explained]
4
England. RCOG (Apr 2008) Green-top Guideline No. 50: Umbilical cord prolapse. 1st ed. pp. 1
[http://www.rcog.org.uk/files/rcog-corp/uploaded-files/GT50UmbilicalCordProlapse2008.pdf]
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Term
What it stands for
Dating Scan
Also referred to as an early ultrasound scan.
25/03/2013
An ultrasound scan recommended to be undertaken between 10 weeks +
0 days and 13 weeks + 6 days5, that is used to determine viability,
calculate gestational length and detect multiple pregnancies.
Deep vein thrombosis Venous thrombosis that occurs in the “deep veins” in the legs, thighs, or
pelvis.6
Early Neonatal Death Death of a live born occurring before 7 completed days after birth.7
Early Ultrasound
Scan
See ‘Dating Scan’.
Eclampsia
Occurrence of one or more convulsions superimposed on pre-eclampsia8.
Elective
A term for clinical procedures that are planned rather than becoming
necessary as emergencies.9
Erb’s palsy
Injury to the nerve roots of the brachial plexus leading to various degrees
of weakness of the affected arm.10
Fetal acidaemia
Cord arterial pH <7.05.11
Fetal Anomaly Scan
An ultrasound scan recommended to be undertaken between 18 weeks +
0 days and 20 weeks + 6 days12, that assesses for structural abnormalities
in the fetus.
Feto-maternal
haemorrhage
Fetal blood entering the maternal circulation.13
Fetus
An unborn baby.14
5
England. NICE (Corrected Jun 2008) CG62 Antenatal Care: Full Guideline, London: RCOG Press, pp. 77
[http://www.nice.org.uk/nicemedia/live/11947/40145/40145.pdf]
England. NICE (2010) CG92 Venous thromboembolism – reducing the risk: Full guideline, London: National Clinical
Guideline Centre at the Royal College of Physicians, pp. 26 [http://www.nice.org.uk/nicemedia/live/12695/47920/47920.pdf]
6
7
Centre for Maternal and Child Health Enquiries (CMACE) (2010). Perinatal Mortality 2008: United Kingdom. CMACE:
London, pp. x [http://www.hqip.org.uk/assets/NCAPOP-Library/CMACE-Reports/36.-July-2010-Perinatal-Mortality-2008.pdf]
8
England. RCOG (Mar 2006) Green-top 10(A): The Management of severe pre-eclampsia/eclampsia. 1st ed. pp. 1
[http://www.rcog.org.uk/files/rcog-corp/uploaded-files/GT10aManagementPreeclampsia2006.pdf]
9
England. NICE (Jul 2008) CG70 Induction of labour: Full Guideline, London: RCOG Press, pp. x
[http://www.nice.org.uk/nicemedia/live/12012/41255/41255.pdf]
10
Adapted from England. NICE (Reissued Jul 2008), CG63 Diabetes in Pregnancy: Full Guideline, London, RCOG Press,
pp. xv [http://www.nice.org.uk/nicemedia/live/11946/41320/41320.pdf]
11
De La Fuente and S. Soothill, P. 2001. Prediction of asphyxia with fetal gas analysis. In Levene MI, Chervenak FA,
Whittle M (Eds.) Fetal and neonatal neurology and neurosurgery (Chapter 26), 3rd edition, London: Churchill Livingstone
12
England. NICE (Corrected Jun 2008) CG62 Antenatal Care: Full Guideline, London: RCOG Press, pp. 154
[http://www.nice.org.uk/nicemedia/live/11947/40145/40145.pdf]
13
England. NICE (Aug 2008) TA156: Routine antenatal anti-D prophylaxis for women who are rhesus D negative, pp. 4
[http://www.nice.org.uk/nicemedia/live/12047/41690/41690.pdf]
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Term
What it stands for
First degree perineal
tear (also referred to
as ‘first degree tear’)
See ‘Perineal tear – first degree’.
Fourth degree
perineal tear (also
referred to as ‘fourth
degree tear’)
See ‘Perineal tear – fourth degree’.
Gestational diabetes
mellitus
Carbohydrate intolerance resulting in hyperglycaemia of variable severity
with onset or first recognition during pregnancy and with a return to normal
after birth.15
Gestational
hypertension
New hypertension presenting after 20 weeks without significant
proteinuria.16
Gestational
proteinuria
Proteinuria occurring in pregnancy.
Also refer to definition of ‘proteinuria’
Haemolytic anaemia, A combined liver and blood clotting disorder which is a complication of
Elevated Liver
pre-eclampsia.17
enzymes and Low
Platelet count
(HELLP)
Hypertension
A single diastolic blood pressure of 110 mmHg or any consecutive
readings of 90 mmHg on more than one occasion at least 4 hours apart.18
Independent Midwife
A fully qualified midwife who has chosen to work outside the NHS in a selfemployed capacity. Independent midwives fully support the principals of
the NHS and are currently working to ensure that all women can access
‘gold standard’ of care in the future.19
Intrapartum
During childbirth.
Jaundice
A yellow coloured tinge to the skin, and a yellowing of the whites of the
eyes. The body fluids of someone who is affected by jaundice can also
become yellow in colour. The medical name for jaundice is icterus.20
14
Fetus definition [http://www.rcog.org.uk/womens-health/patient-information/medical-terms-explained]
15
England. NICE (Corrected Jun 2008) CG62 Antenatal Care: Full Guideline, London: RCOG Press, pp. 205
[http://www.nice.org.uk/nicemedia/live/11947/40145/40145.pdf]
England. NICE (Feb 2010) Hypertension in pregnancy, The management of hypertensive disorders during pregnancy –
Full Guideline, pp pp. 205 [http://www.nice.org.uk/guidance/index.jsp?action=download&o=47351]
16
17
RCOG, Medical terms explained, HELLP syndrome [http://www.rcog.org.uk/womens-health/patient-information/medicalterms-explained]
18
England. NICE (Corrected Jun 2008) CG62 Antenatal Care: Full Guideline, London: RCOG Press, pp. 218
[http://www.nice.org.uk/nicemedia/live/11947/40145/40145.pdf]
19
Independent Midwife description [http://www.independentmidwives.org.uk/?node=750]
England. NICE (May 2010) CG98 Neonatal Jaundice – Full Guideline, London: RCOG, pp. 33
[http://www.nice.org.uk/nicemedia/live/12986/48678/48678.pdf]
20
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Term
What it stands for
Late Neonatal Death
Death of a live born occurring from the seven day and before 28
completed days after birth.21
Live Birth
Delivery of an infant, which, after complete separation from its mother,
shows signs of life.22
Liver cholestasis of
pregnancy (also
referred to as
‘obstetric cholestasis’)
Multifactorial condition of pregnancy characterised by intense pruritus
(severe itching) in the absence of a skin rash, with abnormal liver function
tests (LFTs), neither of which have an alternative cause and both of which
remit following delivery23.
Manual removal
A hand being inserted into the vagina and into the uterus to detach the
placenta from the uterine wall.
Meconium Aspiration The aspiration of meconium into the lungs during intrauterine gasping, or
Syndrome
when the baby takes its first breath, leading to respiratory distress
requiring oxygen and/or other respiratory support.
Neonatal abstinence
syndrome
Symptoms suffered by infants withdrawing from substances to which they
have become physically dependent during intrauterine exposure requiring
regular observations and/or treatment.
Neonatal seizures
A change in behaviour that is caused by sudden, abnormal, and excessive
electrical activity in the brain to a neonate’.24
Neonatal Unit (NNU)
A unit which provides additional care for babies over and above the
essential core postnatal care that all babies should receive. There are
different levels of complexity of additional care, defined by British
Association of Perinatal Medicine (BAPM) categories, which can be
offered by an individual neonatal unit. This is best understood through the
three different types of neonatal units - Special Care Units, Local Neonatal
Units and Neonatal Intensive Care Units.
Neonate
Refers to a baby from birth to 28 completed days after birth.25
Newborn Blood Spot
Screening
A systematic screening programme for newborn babies which tests for a
series of genetic conditions. Every baby is entitled to the test, which
involves the collection of a blood sample from the heel, usually when the
baby is between 5 and 8 days of age.
21
Centre for Maternal and Child Health Enquiries (CMACE) (2010). Perinatal Mortality 2008: United Kingdom. CMACE:
London, pp. x [http://www.hqip.org.uk/assets/NCAPOP-Library/CMACE-Reports/36.-July-2010-Perinatal-Mortality-2008.pdf]
22
Centre for Maternal and Child Health Enquiries (CMACE) (2010). Perinatal Mortality 2008: United Kingdom. CMACE:
London, pp. x [http://www.hqip.org.uk/assets/NCAPOP-Library/CMACE-Reports/36.-July-2010-Perinatal-Mortality-2008.pdf]
23
England. RCOG (Jan 2006) Green -top 43: Obstetric cholestasis. 1st ed. pp. 1 [http://www.rcog.org.uk/files/rcogcorp/uploaded-files/GT43ObstetricCholestasis2006.pdf]
24
Neonatal seizure [http://healthlibrary.epnet.com/GetContent.aspx?token=1d460a90-ed32-4663-892bccb4aae1e348&chunkiid=202856]
The Neonate definition has been adapted from World Health Organisations’ definition of ‘Neonatal Period’ –
[http://www.who.int]
25
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Term
What it stands for
Newborn Hearing
Screening
A screening test, recommended to be undertaken on all newborn babies,
using appropriate electro-acoustic or electro-physiological tests to detect
moderate, severe or profound permanent childhood deafness.
The MSDS only captures information related to the final outcome, and
may therefore be based on any of the 3 stages of the screening test.
Newborn Physical
Examination
Screening (NIPE)
A physical examination recommended for all newborn babies, using
appropriate clinical examination techniques to detect congenital heart
defects (CHD), developmental dysplasia of the hip (DDH), eye pathology
and undescended testes.
NB. The examination is repeated at six to eight weeks of age. Information
on the 6-8 week physical examination is not captured by the MSDS.
Obstetric cholestasis
See ‘Liver cholestasis of pregnancy’.
Perineal tear – first
degree
Injury to perineal skin only.26
Perineal tear –
second degree
Injury to perineum involving perineal muscles but not involving the anal
sphincter.27
Perineal tear – third
degree
A partial or complete disruption of the anal sphincter muscles, which may
involve either or both the external (EAS) and internal anal sphincter (IAS)
muscles.28
Perineal tear – fourth A disruption of the anal sphincter muscles with a breach of the rectal
degree
mucosa.29
Phototherapy
Controlling the levels of bilirubin by placing the baby under a lamp emitting
light in the blue spectrum. Light energy of the appropriate wavelength
converts the bilirubin in the skin to a harmless form that can be excreted in
the urine.30
Placental abruption
Premature separation of the placenta from the uterus which results in
bleeding during the pregnancy.31
26
England. RCOG (Mar 2007) Green-top Guideline No. 29: The management of third and fourth degree tears. 2nd ed. pp. 3
[http://www.rcog.org.uk/files/rcog-corp/uploaded-files/GT29ManagementThirdFourthDegreeTears2007.pdf]
27
England. RCOG (Mar 2007) Green-top Guideline No. 29: The management of third and fourth degree tears. 2nd ed. pp. 3
[http://www.rcog.org.uk/files/rcog-corp/uploaded-files/GT29ManagementThirdFourthDegreeTears2007.pdf]
28
England. RCOG (Mar 2007) Green-top Guideline No. 29: The management of third and fourth degree tears. 2nd ed. pp. 1
[http://www.rcog.org.uk/files/rcog-corp/uploaded-files/GT29ManagementThirdFourthDegreeTears2007.pdf]
29
England. RCOG (Mar 2007) Green-top Guideline No. 29: The management of third and fourth degree tears. 2nd ed. pp. 1
[http://www.rcog.org.uk/files/rcog-corp/uploaded-files/GT29ManagementThirdFourthDegreeTears2007.pdf]
England. NICE (May 2010) CG98 Neonatal Jaundice – Full Guideline, London: RCOG, pp. 34
[http://www.nice.org.uk/nicemedia/live/12986/48678/48678.pdf]
30
31
England. RCOG, BJOG release: New study reveals an association between later placental problems in mums (May
2007) [http://www.rcog.org.uk/news/bjog-release-new-study-reveals-association-between-later-placental-problems-mums]
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Term
What it stands for
Placenta praevia
The placenta being inserted wholly or in part into the lower segment of the
uterus. 32
Postnatal
The period of time immediately after childbirth and to the point of baby’s
discharge from maternity services.
Note – ‘Postpartum’ relates to the mother.
Postpartum
The period of time immediately after childbirth and to the point of the
mother’s discharge from maternity services.
Postpartum
haemorrhage
See ‘Primary postpartum haemorrhage’ and ‘Secondary postpartum
haemorrhage’.
Pre-eclampsia
Pregnancy-induced hypertension in association with proteinuria (> 0.3 g in
24 hours) ± oedema and virtually any organ system may be affected.33
Preterm
Before 37 weeks and 0 days of gestation.34
Primary postpartum
haemorrhage
Loss of 500 ml or more of blood from the genital tract within 24 hours of he
birth of a baby.35
Proteinuria
300 mg excretion of protein in a 24 hour collected urine, two clean catch
urine specimens at least 4 hours apart with 2+ proteinuria by dipstick.36
Puerperal psychosis
A group of serious mental illness that may develop in a mother shortly
after birth.



Mania
Depression
Schizophrenia
37
Pulmonary embolism A blood clot that breaks off from the deep veins and travels round the
circulation to block the pulmonary arteries (arteries in the lung).38
32
England. RCOG (Jan 2011) Guideline No. 27: Placenta Praevia, Placenta Praevia Accreta and Vasa Praevia: Diagnosis
and management. 2nd ed, pp. 1 [http://www.rcog.org.uk/files/rcog-corp/uploaded-files/GT27PlacentaPreviaAccreta2005.pdf]
33
England. RCOG (Mar 2006) Green-top 10(A): The Management of severe pre-eclampsia/eclampsia. 1st ed. pp. 1
[http://www.rcog.org.uk/files/rcog-corp/uploaded-files/GT10aManagementPreeclampsia2006.pdf]
34
England. NICE (Reissued Jul 2008) CG63 Diabetes in Pregnancy: Full Guideline, London: RCOG Press, pp. xix
[http://www.nice.org.uk/nicemedia/live/11946/41320/41320.pdf]
35
England. RCOG Green-top Guideline No. 52: Prevention and management of postpartum haemorrhage. 1st ed. pp. 1
(Mar 2009) [http://www.rcog.org.uk/files/rcog-corp/Green-top52PostpartumHaemorrhage.pdf]
36
England. NICE (Corrected Jun 2008) CG62 Antenatal Care: Full Guideline, London: RCOG Press, pp. 218
[http://www.nice.org.uk/nicemedia/live/11947/40145/40145.pdf]
RCPSych, Mental illness after childbirth –
[http://www.rcpsych.ac.uk/mentalhealthinfoforall/problems/postnatalmentalhealth/afterchildbirth.aspx]
37
England. NICE (2010) CG92 Venous thromboembolism – reducing the risk: Full guideline, London: National Clinical
Guideline Centre at the Royal College of Physicians, pp. 31 [http://www.nice.org.uk/nicemedia/live/12695/47920/47920.pdf]
38
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Term
What it stands for
Retained placenta
When it (the placenta) has not been delivered within 30 minutes of birth
when the third stage is actively managed, and longer than 1 hour when
physiologically managed, without signs of postpartum haemorrhage (PPH)
or maternal collapse.39
Secondary
postpartum
haemorrhage
Abnormal or excessive bleeding from the birth canal between 24 hours
and 12 weeks postnatally.40 For the purpose of the MSDS, secondary
postpartum haemorrhage will only be relevant until the point of discharge
from maternity services.
Severe pre-eclampsia Severe hypertension (a diastolic blood pressure ≥ 110 mmHg on two
occasions or systolic blood pressure ≥ 170 mmHg on two occasions) and
significant proteinuria (at least 1 g/litre).41
Shoulder dystocia
A complication of delivery that requires additional obstetric manoeuvres to
release the shoulders after gentle downward traction has failed.42
Stillbirth
A baby delivered without signs of life after 23 + 6 weeks of pregnancy.43
Symphysis pubis
dysfunction
A collection of signs and symptoms of discomfort and pain in the pelvic
area, including pelvic pain radiating to the upper thighs and perineum.44
Term
Between 37 weeks + 0 days gestation and 42 weeks + 6 days gestation.
Termination of
Pregnancy
The deliberate ending of a pregnancy with the intention that the fetus will
not survive.45
Third degree perineal See ‘Perineal tear – third degree’.
tear (also referred to
as ‘third degree tear’)
Thromboembolic
disorder
Defined using definitions of ‘thrombus’ and ‘embolus’.
39
England. NICE (Corrected Jun 2008) CG55 Intrapartum Care: Full Guideline, London: RCOG Press, pp. 246
[http://www.nice.org.uk/nicemedia/live/11837/36275/36275.pdf]
40
England. RCOG Green-top Guideline No. 52: Prevention and management of postpartum haemorrhage. 1st ed. pp. 1
(Mar 2009) [http://www.rcog.org.uk/files/rcog-corp/Green-top52PostpartumHaemorrhage.pdf]
41
England. RCOG (Mar 2006) Green-top 10(A): The Management of severe pre-eclampsia/eclampsia. 1st ed. pp. 1
[http://www.rcog.org.uk/files/rcog-corp/uploaded-files/GT10aManagementPreeclampsia2006.pdf]
42
Adapted from England. RCOG (Dec 2005) Guideline No. 42:Shoulder Dystocia. 1st ed. pp. 1
[http://www.rcog.org.uk/files/rcog-corp/uploaded-files/GT42ShoulderDystocia2005.pdf]
43
Centre for Maternal and Child Health Enquiries (CMACE). Perinatal Mortality 2008: United Kingdom. CMACE: London,
2010 [http://www.hqip.org.uk/assets/NCAPOP-Library/CMACE-Reports/36.-July-2010-Perinatal-Mortality-2008.pdf]
44
England. NICE (Corrected Jun 2008) CG62 Antenatal Care: Full Guideline, London: RCOG Press, pp. 113
[http://www.nice.org.uk/nicemedia/live/11947/40145/40145.pdf]
Termination of pregnancy definition - Stillbirth definition – Centre for Maternal and Child Health Enquiries (CMACE).
Perinatal Mortality 2008: United Kingdom. CMACE: London, 2010 [http://www.hqip.org.uk/assets/NCAPOP-Library/CMACEReports/36.-July-2010-Perinatal-Mortality-2008.pdf]
45
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Term
What it stands for
Thrombus
A condition in which a blood changes from a liquid to a solid state and
produces a blood clot.
Note – the definition of thrombus is based on the ‘thrombosis’ definition.46
Uterine rupture
A full-thickness separation of the uterine wall and the overlying serosa.47
Venous
thromboembolism
The blocking of a blood vessel by a blood clot formed at or dislodged from
its site of origin. It includes both Deep Vein Thrombosis (DVT) and
Pulmonary Embolism (PE).
Document Control:
The controlled copy of this document is maintained in the HSCIC corporate network. Any
copies of this document held outside of that area, in whatever format (e.g. paper, email
attachment), are considered to have passed out of control and should be checked for
currency and validity.
46
Oxford concise colour medical dictionary, new 3 rd edition, Oxford University Press, 2002
47
Uterine rupture in pregnancy: eMedicine, definition [http://emedicine.medscape.com/article/275854-overview]
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Contents
1.
About this Document
19
1.1.
Purpose and Scope of the Document
19
1.2.
Out of Scope of User Guidance
19
1.3.
Target Audience
19
1.4.
Schedule for Updating this Document
19
2.
Information Standard
20
2.1.
Scope of the Information Standard
20
2.2.
Users of the Information Standard
23
2.3.
Key Components of the Information Standard
23
2.4.
Information Standard Approval Process
24
3.
Background and Strategic Alignment
25
3.1.
Responding to National Requirements
25
3.2.
Project Structure and Stakeholder Involvement
25
3.3.
Defining the data set
26
3.4.
Further definition of the data set (2012)
27
4.
Local Data Collection and Data Flow
28
4.1.
Local data collection process
28
4.2.
Requirements of key personnel involved in the delivery of this data set
29
4.3.
Data to be included in each submission
30
5.
Implementation Guidance
31
5.1.
Explanation of Documentation Available to Data Providers
31
5.2.
Step-by-step implementation guide
33
5.3.
Data Set Output Specification
34
5.4.
Centrally derived data items
140
5.5.
System Conformance to the Standard
142
5.6.
Classification Systems
142
5.7.
Linking events in the care pathway using NHS number
143
6.
Alignment with existing and proposed ISB standards
144
6.1.
CAMHS Secondary Uses Data Set
144
6.2.
CYPHS Secondary Uses Data Set
145
6.3.
Commissioning Data Set (CDS)
146
6.4.
Neonatal Critical Care Minimum Data Set
152
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6.5.
NN4B Data Set
153
6.6.
Smoking and Pregnancy Data Set
154
7.
Clinical Governance
156
8.
Resource and Cost
156
9.
Information Governance
156
9.1.
Consent and Opt Out
156
9.2.
Subject access request and right to begin/cease data processing
157
9.3.
Measures to Ensure Privacy of Patient Level Data
157
9.4.
Data Retention
160
9.5.
Data Quality
160
9.6.
Contractual Issues for Staff
161
9.7.
Skill Mix Changes
161
10. Reporting Guidance
162
11. Maintenance of the Information Standard
163
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1. About this Document
1.1. Purpose and Scope of the Document
The Maternity Services Secondary Uses Data Set is one of three components of the “Maternity and
Children’s Data Set”. The other two components are:


The “Children’s and Young People’s Health Services (CYPHS) Secondary Uses Data Set”
The “Child and Adolescent Mental Health Services (CAMHS) Secondary Uses Data Set”
This document only refers to the Maternity Services Secondary Uses Data Set.
The purpose of this document is to:




Introduce the Maternity Services Secondary Uses Data Set (MSDS) Information Standard.
Describe the manner by which this Information Standard should be used and interpreted by
users, system suppliers and other stakeholders.
Act as a guide to the other documents produced within the project.
Provide additional information on data groups and on some data items, beyond that stated in
the Data Set Output Specification, to further explain their use and validation.
1.2. Out of Scope of User Guidance
The following areas are out of scope of this document:





Detailed justification for the development of the information standard.
ISB Development Methodology. Further information to this is available from
http://www.isb.nhs.uk/how.
Data submission framework (i.e. how data is submitted by data providers to the central data
warehouse). Further information about this is available from the Maternity Data Set Technical
Guidance.
Central data warehouse architecture.
Restating information already accessible from the Data Set Output Specification.
1.3. Target Audience
This document is aimed at:



Managers and clinical leads or organisations providing maternity care services e.g. Heads of
Midwifery, Clinical Directors of Obstetrics.
Information management departments within data provider organisations
IT system suppliers operating within maternity care services.
1.4. Schedule for Updating this Document
This document will be reviewed and updated when necessary. Changes to this document will not
necessitate further approval from the ISB; however, this is on the understanding that the changes do
not affect the scope of the Information Standard.
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2. Information Standard
The Maternity Secondary Uses Data Set Information Standard is the specification of a patient-level
data-extraction (output) standard intended for maternity service providers in England. It forms part of
an overall Maternity and Children’s Data Set, which incorporates the following individual information
standards:

Child and Adolescent Mental Health Services (CAMHS) Secondary Uses Data Set

Children’s and Young People’s Health Services (CYPHS) Secondary Uses Data Set

Maternity Services Secondary Uses Data Set (MSDS)
This Information Standard has been approved by the ISB and has been assigned standard number
ISB 1513. This mandates the patient-level Maternity Secondary Uses Data Set as a national data
standard.
The ISN does not directly place any requirement on system suppliers to accommodate the MSDS
within their systems. The contractual agreement between data providers and system suppliers will
dictate whether system suppliers have to abide by the ISN and at what cost.
2.1. Scope of the Information Standard
In Scope
Out of Scope
Patient Scope
Women and babies of all nationalities in contact
with maternity services, irrespective of whether
the mother is entitled to that care or has been
allocated a NHS number.
There is only one data item related to the
mother’s partner, based only on information
supplied by the mother. The data set does not
capture any information from the ‘partner’s
record’.
Geographic Scope
Services provided within NHS England.
Services provided outside NHS England (e.g.
Wales, Scotland, Ireland).
The data subject’s place of residence has no
bearing on the data set scope. If a data subject is NB. This only relates to those activities of the
resident outside England, but receives maternity care pathway that are undertaken by noncare in England, those events are within scope.
English organisations. For example, if a mother
receives antenatal care in England but delivers
in Scotland, only the activities related to labour
& delivery will be out of scope.
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Organisation Scope
Events and episodes of care within maternity
services provided by NHS acute, community and
foundation Trusts.
This may include:






Maternity services
Radiology services
Pathology services
Gynaecology services
Theatre Services
Neonatal Services
Maternity care services provided by GPs, private
clinics and independent midwives where
commissioned by an NHS Trust.
Events and episodes of care delivered by Child
Health services.
NB. Depending on local processes, Newborn
Hearing Screening and Blood Spot Card results
may be captured by the maternity service or the
Child Health service or both.
Child Health data providers will submit common
data items via the Children’s and Young
People’s Health Services (CYPHS) Secondary
Uses Data Set process.
Other maternity care services provided by GPs,
private clinics and independent midwives.
NB. This data should be provided by the
commissioning Trust.
Data Set Scope
The ‘output data set’ as defined by this
information standard. The MSDS defines “what
should be extracted” from clinical and operational
IT systems.
The MSDS is not a ‘clinical data set’, so does
not define “what should be captured” by clinical
IT systems.
Data providers may adopt any local data
collection process and system they see fit, so long
as the system can output data as per the MSDS.
Data items captured in IT systems.
Data providers must submit all MSDS data items
that can be derived from clinical and operational
IT systems.
This Information Standard does not mandate
that data providers upgrade their IT systems to
deliver the full data set. Where one or more
data items are unavailable from local IT
systems, those data items do not need to be
submitted to the central data warehouse.
For the mother, data should be captured from ‘first Any activities occurring before first contact with
contact’ and to either the point of maternal
maternity care services and after post-maternity
discharge from maternity services or maternal
services discharge.
death up to postpartum discharge.
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For the baby, data needs to be captured from birth Any activities occurring post-maternity services
and to either
discharge (unless a neonatal death occurs
before 28 completed days of birth).
 The point of transfer to Child Health
services. This will occur on discharge
from maternity services or the neonatal
unit.
or

Neonatal death before 28 completed days
of birth (this is irrespective of whether the
death occurred whilst the baby was within
or outside maternity services).
Where a neonatal death occurs after maternity
services discharge, but within 28 days, NHS
Trusts may not have the processes in place to
inform maternity services of these deaths. In such
cases, it is recommended that NHS Trusts resolve
this issue in order to deliver this crucial aspect of
the MSDS.
It was recognised that the proposed MCDS data
set was too large for a ‘big-bang' approach;
therefore, the sponsor agreed to an incremental
approach. Consequently, the Maternity Expert
Reference Group (MERG) and the sponsor
identified a priority sub-set of data items and
agreed the scope of the initial implementation
phase. The information standard relates to this
phase 1 data set only.
Non-phase 1 data items, which are specified in
the Reference Data Set, are outside the scope
of the information standard. For completeness
purposes, the Reference Data Set includes the
phase 1 data items (and these are clearly
marked in the document). Subsequent
implementation phases to the initial release
have been planned but not scheduled. All
subsequent phases are subject to testing
outcomes, funding and ISB approvals.
Exceptions
The following areas are exceptions to the Maternity Services Secondary Use Data Set scope:








Clinical data collection standards within the maternity care pathway.
System functionality or design: whilst the standard will provide details of ‘what’ and ‘how’
data should be submitted, it does not stipulate any standard on the functionality or design of
local clinical and operational systems, although if data is easy to collect and synchronise
with care pathways it will improve the quality of the data provided
Activities undertaken after discharge from maternity services
Services provided by non-NHS organisations (unless commissioned by the NHS)
Services rendered outside England.
Paper Records: The data submission file has been designed to split the data submissions
into a number of data segments related to specific activities. Where data requirements in
specific data segments are predominantly recorded on paper and not transcribed to an
electronic form, NHS Trusts are not required to submit those data segments in the first
instance
Independent midwives and private providers are not required to make submissions, unless
commissioned by the NHS
Data captured in GP systems.
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2.2. Users of the Information Standard
The MCDS will be used in all organisations providing maternity care services, commissioned or
provided by the NHS.
There a number of stakeholders that will make use of the MSDS:





Commissioners: such as the NHSCB and CCGs may use the MCDS to plan and deliver
maternity services in line with local and national priorities.
Service providers: such as NHS acute, community and foundation Trusts may use the
MCDS to manage expectations and trends in maternity services, possibly to ensure the
availability of appropriate resources to continue providing appropriate maternity care services.
For example, where there is an annual increase in hospital births, providers will want to
ensure sufficient resources are available to accommodate the mother and baby through the
labour and delivery stage of the care pathway.
Regulatory bodies: such as the Care Quality Commission (CQC) and Monitor may use the
MSDS to assess performance of commissioners and service providers.
Professional bodies: such as the Royal College of Obstetricians and Gynaecologists
(RCOG), the Royal College of Midwives (RCM), the National Institute for Health and Clinical
Excellence (NICE), the UK National Screening Committee (UK NSC) and the Centre for
Maternal and Child Health Enquiries (CMACE), may use the MSDS to develop operational
and reporting standards and then assess service provider’s conformity to those standards.
Research institutions may use the MSDS to perform national and local analysis on certain
areas of maternity care. This may involve using the MSDS to initiate in-depth research or
possibly reviewing trends in the maternity care pathway.
For the protection of patient identity, the data will only be published in anonymised form. This will be
through the non-disclosure of identifiable data items such as the NHS number and date of birth.
2.3. Key Components of the Information Standard
The following documents make up the key components of the information standard:
File Name
Document Title
Critical to
implementing the
MSDS data set?
ISB Information Standards Notice
Yes
ISB 1072 Child and Adolescent Mental Health
Services Secondary Uses Data Set -
No
Specification
Maternity Services Secondary Uses Data Set
(MSDS) Specification
Maternity Data Set
Output Specification
Maternity Services Secondary Uses Data Set Output Yes
Specification
Maternity Data Set Data Model
Maternity Services Secondary Uses Data Set Model
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Yes
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File Name
Document Title
Critical to
implementing the
MSDS data set?
Maternity Data Set
Technical Guidance
Maternity Services Secondary Uses Data Set
Technical Guidance
Yes
CAMHS Data Set User Maternity Services Secondary Uses Data Set User
Guidance
Guidance
Yes
CAMHS Data Set
Validation Reporting
Specification
Maternity Services Secondary Uses Data Set
Validation and Reporting Specification
Yes
Maternity Data Set
Extract Specification
Maternity Services Secondary Uses Data Set Extract Yes
Specification
Maternity Data Set
System Conformance
Checklist
Maternity Services Secondary Uses Data Set System Yes
Conformance Checklist v1.4
Maternity Data Set
Data Source
Maternity Services Secondary Uses Data Set
(MSDS) Data Source
No
Maternity Reference
Data Set
Maternity Services Secondary Uses Reference Data
Set
No
Note – The Reference Data Set is not part of this
Information Standard
Maternity Services
Business and
Information
Requirements
Maternity Services Secondary Uses Data Set
Business and Information Requirements
No
All documents are available for download at:
http://www.ic.nhs.uk/maternityandchildren/maternity
2.4. Information Standard Approval Process
The standard has the following approvals:

Review of Central Returns Steering Committee (ROCR): ROCR/OR/0277/000MAND the original
standard elapsed in November 2012. Further to this, there will be a new submission going for
ministerial approval in March 2013. The license is due to be issued at the end of March 2013.

The Information Standards Board (ISB) for Health and Social Care: Standard Number ISB 1513.

National Information Governance Board (NIGB) approval of the proposed changes is not required
as the Health and Social Care Information Centre is no longer required to apply for Section 251
support where mandated to collect data and when acting as data controller. This is set out in
Sections 254 and 255 of the Health and Social Care Act 2012. A Privacy Impact Assessment has
instead been carried out in relation to the MCDS project.
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3. Background and Strategic Alignment
3.1. Responding to National Requirements
The Maternity Services Secondary Uses Data Set (MSDS) has been developed by the HSCIC on
behalf of the Department of Health in support of the NHS White Paper, Equity and excellence:
liberating the NHS and the Information Revolution consultation document, which states that
information should be used more effectively and collected under consistent standards.
The development of the MSDS commenced as a result of the 2004 publication of National Service
Framework (NSF) for Children, Young People and Maternity Services. Standard 11 of the NSF
focuses on Maternity Service and addresses the requirements of women and their babies during
pregnancy, birth and post-birth.
Throughout the development cycle, due attention and consideration were placed on related
strategies and frameworks. For example:





Maternity Matters (2007).
Towards Better Births; A review of Maternity Services in England (2008).
Healthy Child Programme (2009) (Formerly Child Health Promotion Programme).
Healthy lives, brighter futures - the strategy for children and young people’s health (2009).
Maternity & early years (2010).
MSDS is a key driver to achieving better outcomes of the care for mothers, babies and children. The
data set provides comparative, mother and child-centric data that will be used to improve the
efficiency of services; improve clinical quality; and develop and target services in a way that improves
health and reduces inequalities.
This includes monitoring:



Implementation of key areas of Standard 11 of the NSF and supporting strategies &
frameworks.
Relevant outcomes of the ‘The NHS Outcome Framework 2011/12’ (and its ongoing periodic
iterations).
Clinical and operational standards of maternity care.
It also supports a variety of other ‘secondary use’ functions such as commissioning, clinical audit,
research, service planning, and performance management at both local and national level.
3.2. Project Structure and Stakeholder Involvement
The development of the MSDS has been overseen by the Maternity Expert Reference Group
(MERG) which consisted of clinicians, regulatory bodies, professional bodies, commissioners and
service providers.
All clinical terms within the MSDS have been approved by the Chair and appropriate members of the
Maternity Expert Reference Group (MERG).
Where possible, the data set has re-used or adapted nationally recognised definitions, as developed
by authoritative bodies, such as:




Royal College of Obstetricians and Gynaecologists (RCOG)
Royal College of Paediatrics and Child Health (RCPCH)
Royal College of Midwives (RCM)
UK National Screening Committee (UK NSC)
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National Institute for Clinical Excellence (NICE)
Only where reliable sources have been unavailable, have terms been defined and validated by
appropriate members of the MERG.
3.3. Defining the data set
Maternity Care Pathway
Pregnant
First Contact
Midwife
GP
Standardised Risk and Needs Assessment
Antenatal care
By 10-12 weeks
Midwifery Care
Maternity Team Care
Transfer to Other Settings Arranged Through Local Networks
Birth
Midwifery Care
at Home
Postnatal Care
Midwifery Care in a Midwifery
Midwifery Care
Unit / Birth Centre Inside or
in Hospital
Home
Maternity Team
Care in Hospital
Supported by Information
With Context of National Standards
Accessing maternity care
At 6-8 weeks of pregnancy
Community
Discharge from Maternity Service
The requirements phase of the data set development stage yielded a 1,010 data items. This is
referred to as the Full Data Set. The impracticality of implementing such a large data set was
recognised early on in the development cycle, and so the sponsor and MERG agreed to smaller
implementation model, which resulted in the MSDS. The MSDS consists of 154 data items and is a
subset of the Full Data Set.
The MSDS is also referred to as the Phase 1 Data Set since it is the first set of data items to be
implemented from the Full Data Set. For completeness purposes the Reference Data Set includes
the phase 1 data items (although, for clarity purposes, these are clearly marked in the document).
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Clinical Risks
Since the MSDS is not a clinical data set, implementation does not pose any clinical risks although
the Output Specification does contain data items generally included in clinical data sets as it seeks to
re-use clinical data for national analysis and reporting (i.e. “secondary uses”). Furthermore, the
reporting stage will be used by stakeholders to extract information on organisation’s conformance
towards clinical standards.
Due to the inclusion of clinical data items in the data set, the development stage made all efforts to
link the MSDS Output Specification as closely as possible to clinical practice, thus mitigating clinical
risks. This was managed by:


The Maternity Expert Reference Group (MERG) - centred on clinical and operational
standards, the MERG identified the requirements the data set should deliver and these were
subsequently used to derive the data items. This effectively provided the link back to clinical
standards.
The data discovery exercise – the draft data set was compared against operational data
collection in data provider organisations. Where differences were identified, appropriate
changes were made to the data set.
3.4. Further definition of the data set (2012)
A thorough review of the data set and data designs by both HSCIC and NHSCFH teams in 2012 led
to some significant changes in both the design and delivery of data set.
Significant flaws within the original design had omitted to include “date marker” data items in a
number of the data groups. These date markers are required to ensure that the central data
warehouse can successfully validate that a group of data does fall within the required reporting
period.
A full data model for the output data set was also developed to clearly define the relationships
between the data groups.
At the Maternity event in Leeds on 13th July 2012, data providers opted to transmit data using a XML.
The meeting rejected the original proposal of transmitting data using a “flat file” of records with tildeseparated data items.
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4. Local Data Collection and Data Flow
4.1. Local data collection process
The MSDS consists of data items that are likely to be captured across a number of services such as
maternity, pathology, radiology, gynaecology and neonatology. It is likely that each service will
operate a dedicated IT system for meeting clinical and operational requirements. Lessons learned
from the data set development process demonstrated that the most efficient method of meeting the
requirements of the data set is for data providers to continue capturing data in their existing systems,
but to feed the data into a local data warehouse. Data providers can then generate the monthly
submission file from their local data warehouse.
In broad terms, the key requirements of the MSDS are for data providers to:



Continue capturing clinical care data in local IT systems.
Extract and group patient-level data from local IT systems, in line with the Maternity Data Set
Output Specification.
Submit data to the central data warehouse, as defined by the Maternity Data Set Technical
Guidance.
Local Data Collection Process
Clinical care data
Capture data
Extra
ct da
ta
PAS
Capture data
Extract data
Maternity System
data
Create Submission
File for Reporting
Period in format
defined by the
Maternity Dataset
Output Specification
tr
Ex
t
Extrac
ted
ac
Capture data
Covert extracted data
into data items defined
by MSDS Output
Specification
MSDS Data
Submission
File
da
ta
Radiology System
ra
Ext
ct d
ata
Local Data
Warehouse
Capture data
Neonatal System
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4.2. Requirements of key personnel involved in the delivery
of this data set
The majority of the information defined within the MSDS will already captured routinely by maternity
professionals and administrative staff as part of their existing work practices for the on-going care of
the mothers and babies.
Heads of Midwifery will be responsible for capturing the information as part of the on-going care of
mothers and babies. They will be required to:




Familiarise themselves with the Maternity Data Set Output Specification to understand what
data items are mandated by this Information Standard.
Assist their organisation’s IT or Information Management service in completing the Maternity
Data Set Conformance Checklist to assess what proportion of the Maternity Data Set Output
Specification data items are available from the their organisation’s local IT systems.
Ensure they understand and implement the information governance approach adopted for this
data set, which can be found in the Information Governance section of this document.
Explain to operational and clinical staff the importance of capturing data for the MSDS.
Administrative staff will also be responsible for capturing information as part of the on-going care of
the mothers and babies. For example, demographic information during registration.
Clinical staff, such as Midwifes and Obstetricians, will need to ensure that they:


Capture the Maternity Data Set Output Specification data items in an accurate and timely
manner.
Understand the deployed IG approach, especially in relation to patient consent.
IT or Information Management staff will need to:






Work with Heads of Midwifery and appropriate IT system suppliers in completing the
Maternity Data Set Conformance Checklist.
Ensure IT systems are capable of identifying patients who opt-out of the MSDS.
Collate information from the various disparate systems.
Ensure data quality, including accurate linkage of patient records
Create periodic data submission files and submit these to the central data warehouse in line
with the submission protocols and timetable.
Analyse and respond to validation errors, warnings and diagnostics returned from the central
data warehouse.
Suppliers of maternity and associated systems: will need to:


Develop systems to ensure that data items can be captured electronically or derived and
output to nationally agreed standards to produce the MCDS.
Assist the data provider’s IT staff in completing the Maternity Data Set Conformance
Checklist.
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4.3. Data to be included in each submission
The maternity care pathway spans a number of months, so mothers and babies receiving care will be
at different points on the maternity care pathway. Some mothers will have just started the care
pathway, some will be partway through and some will be near the end.
Only data groups referring to events or episodes that have occurred within the reporting period
should be included in a submission file. Groups submitted that relate to events or episodes that took
place during different reporting periods will be rejected by the central data warehouse.
For this reason, there is no requirement for data providers to provide historic data relating to events
or episodes occurring before the start date of the first agreed reporting period. It is accepted that
mothers and babies with events prior to this start date will have incomplete data that does not cover
their entire maternity care pathway.
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5. Implementation Guidance
5.1. Explanation of Documentation Available to Data
Providers
A comprehensive set of documentation has been developed by the project team. This is designed to
support data providers through the process of compilation of submissions, the understanding of
errors and warnings produced by the central data warehouse, and an explanation of the data extracts
returned.
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Document
Description of Use
Data Model
The data model provides a pictorial representation of the output
data set. The data model clearly defines the referential integrity
that will be enforced when the submission file is validated.
Data Set Output Specification
Defines the data items that make up the various groups within the
output data set. Each data item is fully described and the expected
format and valid values are also included.
It further defines data linkage between the different groups.
XML Schema
Defines the exact layout of the XML transmission file that should be
constructed by data providers to deliver the data set to the central
data warehouse.
System Conformance
Checklist
Presents the Output Data Set Specification in the form of a
checklist, so that data providers can map how they can collect each
data item from the systems at their disposal.
Technical Guidance
Further explains the data submission process, the submission
windows, and gives advice regarding construction of the data
submission XML file.
User Guidance (this
document)
Helps data providers to further understand the process and
provides background behind the information standard.
Provides additional information over and above the basic
information provided in the Data Set Output Spec
Validation Reporting
Specification
Documents the error/warning reports that data providers can view
and download after a submission file has completed validation.
Examination of this spec will enable data providers to understand
more fully why their submission may be generating errors and
warnings.
The error/warning reports will always provide sufficient information
to enable data providers to take remedial action to improve their
submission data quality prior to re-submission of their file.
Extract Specification
Documents the definition of the extract file that data providers can
expect to be able to download after post-deadline processing has
been completed.
This includes definition of all the derived data items that will be
generated by the post-deadline processing.
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5.2. Step-by-step implementation guide
Step
Description
Understand the background to Review this User Guidance to fully understand the background,
the project, and the scope of
objectives and scope to this Information Standard.
the Information Standard
Understand how the data is
grouped within the data set
Review the Data Model and the Output Data Set Spec to
understand at a higher level how the data items are grouped, and
how those groups relate to each other.
Decide whether and how data
items will be collected – Data
Mapping.
Look more closely at each individual data item in the Output Data
Set Spec and check whether local systems record the data in a
way that means it can be submitted within the MSDS.
The System Conformance Checklist can be used to mark off each
data item and record progress towards mapping each data item.
The User Guidance provides further support regarding extra
validations and information not covered by the Output Data Set
Spec.
Ensure the organisation
complies with Information
Governance requirements.
The User Guidance explains the Information Governance (IG)
issues surrounding the data set. Caldicott Guardians and the
Maternity Services lead MUST:


Review the Information Governance Guidelines within the
User Guidance to understand how data submission, storage
and reporting processes handle identifiable and sensitive
data items.
Review management of the consent issues and put in place
local processes.
Submission Process
Review the Technical Guidance to fully understand the data
submission process.
BSP Login
Undertake the authorisation process to enable members of staff to
be authorised to access the Bureau Service Portal (BSP) to upload
submission files.
Instructions are available from the MCDS website.
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Step
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Description
Construct data submission file Use local processes and technologies to generate the XML
submission file.
The Information Standard does not stipulate any particular local
processes that should be used to generate the required output file.
It may be that some data providers will construct a temporary local
data warehouse to enable them to aggregate data from a number
of different sources.
The Technical Guidance provides further support on the
submission process and the XML Schema defines the exact
structure and content of the submission file.
Fully understand the validation The Validation Reporting Spec defines the reports that will be
reporting provided by the
returned to data providers by the central data warehouse and lists
central data warehouse.
all the error and warning messages that may be produced. The
spec also defines diagnostic (data quality) reporting that will be
returned.
Review this spec to ensure a thorough understanding of the errors
and warnings that may be produced and also how they can be fixed
for later submissions.
Fully understand the postdeadline extracts that will be
available to data providers
The Extract Spec defines the content of the extract file and also all
the derived data items that will be generated by the post-deadline
processing.
Data providers will need to consider how they may use the extract
file.
5.3. Data Set Output Specification
This document makes no attempt to re-describe the Maternity Data Set Output Specification as that
document is very comprehensive. However, this document will provide further clarity where this is
deemed to be necessary. This includes fully explaining how groups may or may not repeat and
extending description and explanation of data items where space does not permit within the data set
output specification.
5.3.1. Overview
The Maternity Data Set Output Specification fully defines the data items within output data set. The
Output Specification splits the data set into a number of groups, each containing related data items.
An output data set describes the set of data items data providers need to extract from local systems
and submit to the central data warehouse. An output data set is distinctly different from clinical data
set, such as a Patient Administration System (PAS), in that it only defines the data that should be
extracted, and so does not directly support patient care. In contrast, a clinical data set specifies data
standards for clinical or operational purposes.
In many cases, the output data item will be identical to the operational definition. However the two
may differ both in terms of the format of the data item and the range of values presented.
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The operational system may represent the data in a different manner or in more granularity; however,
providing the operational data items can be mapped to the output data set, the operational system
will not require any modification. This concept is illustrated in the following table:
Data Provider System (Clinical data set)
MSDS Output Specification
Data item name
Format/Values
Data item name
Format/values
Disability
- Sensory disability
Physical disability
status (Mother at
booking)
Yes
- Motor impairment
…….
…….
- Mental disability
No
- None
Blood loss at
delivery
Medical History
n2 – representing
millilitres
…….
…….
- Type 1 diabetes
Maternal critical
incident
PPH >=500ml and
<=999ml
Maternal critical
incident
PPH >=1000ml and
<=1499ml
Maternal critical
incident
PPH >=1500ml
Maternity
complicating medical
diagnosis type
(Mother at booking)
…….
Diabetes
…….
…….
- Type 2 diabetes
…….
Blood spot screening
offer status
(Phenylketonuria)
- Offered and declined
- Offered and accepted
- Not offered
- Ineligible
- Offered and declined
- Offered and accepted
Blood spot card
offer status
- Not offered
- Ineligible
- No response to offer
Blood spot screening
offer status (Sickle
cell disease)
- Offered and declined
- Offered and accepted
- Not offered
- No response to offer
- Ineligible
- No response to offer
Blood spot screening
offer status (Cystic
fibrosis)
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- Offered and declined
- Offered and accepted
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Data Provider System (Clinical data set)
Data item name
Format/Values
V2.1
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MSDS Output Specification
Data item name
Format/values
- Not offered
- Ineligible
- No response to offer
Blood spot screening
offer status
(Congenital
hypothyroidism)
- Offered and declined
- Offered and accepted
- Not offered
- Ineligible
- No response to offer
Blood spot screening
offer status (Medium
chain acyl coa
dehydrogenase
deficiency)
- Offered and declined
- Offered and accepted
- Not offered
- Ineligible
- No response to offer
In each of the above scenarios, the input data items will map to the output data items.
It is possible that data providers may use the MSDS for local system implementation, and
consequently only capture data as per the data set. However, this is imprudent and against the
recommendations of the Maternity Expert Reference Group. If the MSDS is implemented as a
clinical data standard, there is a possibility that key clinical care data items will be omitted from local
systems and may adversely impact clinical care.
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5.3.2. Linkage and Identifier Data Items
The linkage data items are fully described within the Data Set Output Specification.
All records for a mother and a baby are linked through their Local Patient Identifier within the
submission file. Whilst the mother’s and baby’s NHS number should be supplied wherever it is
known, the project accepts that there may be occasions where the NHS number is not known.
When the NHS number is provided this will be used instead of the Local Patient Identifier as the
primary unique identifier for a mother or baby.
The capture of the NHS number is vital as this is the only identifier that allows the mother and baby to
be tracked across different organisations or across a single organisation when multiple Local Patient
Identifiers have been used for a mother or baby.
Although this is not a mandated field, as not all mothers and babies have NHS numbers, data quality
reports will be produced to identify the completeness of this field and it is recommended that local
care providers use this as one of the primary data quality metrics for all patient level data sets.
In cases where a mother’s NHS number is unavailable (which may be because the mother or baby
does not possess one) data providers must submit a null NHS number and [07] Number not present
and trace not required in NHS NUMBER STATUS INDICATOR (MOTHER)/(BABY).
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5.3.3. MAT001 Mother’s Demographics
MAT001 Mother’s Demographics
Description
This group contains information on patient identifiers, demographic information, and
organisational data. The collection of these data items can be used to analyse
outcomes across different ethnic groups, age groups and geographic locations.
Providers should supply MAT001 data as it was at the end of the reporting period
Providers must populate all known data items even if they are unchanged since the last
submission. Do not just provide data for all "changed" data items.
Group Level Validation and Repeating Rules
These rules are fully described in the appropriate section for this group within the
document Maternity Data Set Technical Output Specification.
Additional Notes on Data Items
Data Item Name
Additional Notes
LOCAL PATIENT
IDENTIFIER
(MOTHER)
This is the unique system identifier that identifies the mother.
This is the primary key that enables groups of data to be joined
together. As such this is a mandated item and the record will be
rejected if it is not included within this group.
Where multiple systems are used it is acceptable to include a
prefix to the Local Patient Identifier, which relates to the system.
The prefix enables each identifier to remains truly unique for all
submissions from an organisation.
Duplicate Local Patient Identifiers within the same submission
file will cause the entire file to be rejected. Duplicate Local
Patient Identifiers across multiple submission files will cause
both records to be rejected even if it is unique within each
submission file.
ORGANISATION
CODE (LOCAL
PATIENT
IDENTIFIER
(MOTHER))
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This will identify the organisation where the Local Patient
Identifier was issued. It is necessary where organisations have
gone through a merger or split into a new or existing
organisation.
If Local Patient Identifiers are not modified during the merger or
split of an organisation, then the issuing Organisation Code of
the Local Patient Identifier (even if now discontinued) should be
sent in this field. However if the Local Patient Identifier has been
modified since the organisation change i.e. by prefix etc, then
the new organisation code should be used.
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NHS NUMBER
(MOTHER)
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The importance of the NHS Number
When the NHS number is provided this will be used instead of
the Local Patient Identifier as the primary unique identifier for a
mother or baby.
The capture of the NHS number is vital as this is the only
identifier that allows the mother and baby to be tracked across
different organisations or across a single organisation when
multiple Local Patient Identifiers have been used for a mother or
baby.
Although this is not a mandated field, as not all mothers and
babies have NHS numbers, data quality reports will be produced
to identify the completeness of this field and it is recommended
that local care providers use this as one of the primary data
quality metrics for all patient level data sets.
No NHS number
In cases where a mother’s NHS number is unavailable (which
may be because the mother does not possess one) data
providers must submit a null NHS number and [07] Number not
present and trace not required in NHS NUMBER STATUS
INDICATOR CODE (MOTHER).
Surrogate pregnancy
The data set does not capture whether the mother is a
surrogate. In the case of a surrogate pregnancy, the NHS
number must be of the mother carrying the baby.
NHS NUMBER
STATUS
INDICATOR CODE
(MOTHER)
In most cases, this data item will be flowed with value [01] Number present and verified. The [01] will indicate that the data
provider has validated the number against the central Personal
Demographics Service (PDS), and therefore facilitates reliable
data linkage.
Data providers may flow data for patients with a NHS number
status indicator code other than [01] and they will be accepted,
however, reports that need reliable linkage of segments will
exclude these data segments (unless reliable linkage is
available via LOCAL PATIENT IDENTIFIER data items).
PERSON BIRTH
DATE (MOTHER)
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The data set does not capture whether the mother is a
surrogate. Consequently, in the case of a surrogate pregnancy,
the date of birth will be of the mother carrying the baby.
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POSTCODE OF
USUAL ADDRESS
(MOTHER)
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The postcode of usual address as stated by the person. If the
person has no fixed abode this should be recorded with the
appropriate code (ZZ99 3VZ).
For overseas residents, the postcode will be recorded in the
format ZZ99 xxZ, where xx denotes the country pseudo
postcode. A full list of pseudo postcodes is available from:
http://nww.connectingforhealth.nhs.uk/ods/downloads/officenatst
ats
ETHNIC CATEGORY
(MOTHER)
The [Z] Not Stated national code should only be used where the
patient has been asked and has declined to provide their ethnic
category because of refusal or the inability to choose.
The [99] Not Known national code should be used where the
patient has not been asked or where the patient was not in a
suitable condition to be asked.
PERSON DEATH
DATE TIME
(MOTHER)
This captures information on maternal deaths within the
antenatal, intrapartum and postpartum periods. The
postpartum period will only cover deaths during the period the
mother is in the care of maternity services (i.e. up to point of
discharge from maternity services).
This must be submitted for any known death not only where a
death certificate is issued.
Data providers also report maternal deaths to MBRRACE-UK
(Mothers and Babies - Reducing Risk through Audits and
Confidential Enquiries across the UK) as part of the national
Maternal, Newborn and Infant Clinical Outcomes Review
Programme.
https://www.npeu.ox.ac.uk/mbrrace-uk
Data submission to MBRRACE-UK must continue. Data
providers must ensure that the data submitted for a particular
mother to the MCDS central data warehouse is consistent with
the data submitted to MBRRACE-UK.
NB. Whilst both MCDS and MBRRACE-UK capture maternal
death data, MCDS only captures death up to the point of
discharge from maternity services, whereas MBRRACE-UK
captures deaths up to 6 months after the end of pregnancy.
ORGANISATION
CODE (CODE OF
COMMISSIONER)
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This is the organisation code of the organisation that is
commissioning the healthcare.
The organisation code should be current at the end of the
reporting period.
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5.3.1. MAT003 GP Practice Registration
MAT003 GP Practice Registration
Description
This group contains information on the mother’s current and historic registered GP
Practice(s). The collection of these data items can be used to support the identification of
the commissioner.
Providers should supply MAT003 data as it was at the end of the reporting period
Group Level Validation and Repeating Rules
These rules are fully described in the appropriate section for this group within the
document Maternity Data Set Technical Output Specification.
Additional Notes on Data Items
Data Item Name
Additional Notes
LOCAL PATIENT
IDENTIFIER
(MOTHER)
This is the unique system identifier that identifies the mother.
This is the primary key that enables groups of data to be joined
together. As such this is a mandated item and the record will be
rejected if it is not included within this group.
Where multiple systems are used it is acceptable to include a
prefix to the Local Patient Identifier, which relates to the system.
The prefix enables each identifier to remains truly unique for all
submissions from an organisation.
Duplicate Local Patient Identifiers within the same submission
file will cause the entire file to be rejected. Duplicate Local
Patient Identifiers across multiple submission files will cause
both records to be rejected even if it is unique within each
submission file.
GENERAL MEDICAL
PRACTICE CODE
(PATIENT
REGISTRATION
(MOTHER))
Where the mother is not registered to a GMP Practice, the data
provider must submit V8199Z.
Where the GMP Practice Code is not applicable, the data
provider must submit V81998.
Where the GMP Practice Code is not known, the data provider
must submit V81999.
START DATE (GMP
REGISTRATION)
The start date on which the mother registered with the General
Medical Practice. This field is primarily to track changes to the
GP and their commissioner during the pregnancy.
This field should only be populated if the actual start date is
known. If this is not known then it is acceptable to leave this field
blank.
If the mother changes General Medical Practice whilst under the
care of Maternity Services then it is expected that the start date
of her new General Medical Practice will be populated.
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END DATE (GMP
REGISTRATION)
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The end date on which the mother registered with the General
Medical Practice.
If this field is left blank the General Medical Practice Code
recorded in this table will be assumed to be current.
If the mother changes General Medical Practice whilst under the
care of Maternity Services then it is expected that the end date
of her previous General Medical Practice will be populated.
5.3.2. MAT101 Booking Appointment Details
MAT101 Booking Appointment Details
Description
This group captures information on the mother as it was at the booking appointment.
NICE CG62 states that the booking appointment should ideally occur within 10 weeks
gestation48, but, due to varying circumstances, it may occur later. Data providers should
submit this group irrespective of how early or late in pregnancy the booking appointment
occurred.
Group Level Validation and Repeating Rules
These rules are fully described in the appropriate section for this group within the
document Maternity Data Set Technical Output Specification.
Additional Notes on Data Items
Data Item Name
Additional Notes
48
England. NICE (Corrected Jun 2008) CG62 Antenatal Care: Full Guideline, London: RCOG Press, pp. 78
[http://guidance.NICE.org.uk/CG62]
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APPOINTMENT
DATE (FORMAL
ANTENATAL
BOOKING)
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This is the primary key that enables groups of data to be joined
together. As such this is a mandated item and the record will be
rejected if it is not included within this group.
Multiple visits
Where the booking appointment is spread over two or more
visits, this data item will capture the date of the last visit (i.e. the
point at which the assessment was completed).
Alignment to national indicators
This data item can report on the 2010/11 Tier 2 Vital Sign:
‘Percentage of women who have seen a midwife or maternity
healthcare professional, for assessment of health and social
care needs, risks and choices by 12 completed weeks of
pregnancy’49.
This vital sign is also a Public Service Agreement (PSA)
indicator (PSA 19) for spending period (2008-2011). The
definition for specific elements of the vital sign / PSA indicator is
available from the HM Treasury website50.
LOCAL PATIENT
IDENTIFIER
(MOTHER)
This is the unique system identifier that identifies the mother.
This is the primary key that enables groups of data to be joined
together. As such this is a mandated item and the record will be
rejected if it is not included within this group.
Where multiple systems are used it is acceptable to include a
prefix to the Local Patient Identifier, which relates to the system.
The prefix enables each identifier to remains truly unique for all
submissions from an organisation.
Duplicate Local Patient Identifiers within the same submission
file will cause the entire file to be rejected. Duplicate Local
Patient Identifiers across multiple submission files will cause
both records to be rejected even if it is unique within each
submission file.
49
12 week assessment Vital Sign
[http://www.dh.gov.uk/en/publicationsandstatistics/publications/publicationspolicyandguidance/dh_110107]
50
PSA 19 [http://webarchive.nationalarchives.gov.uk/+/] [http://www.hm-treasury.gov.uk/pbr_csr07_psaindex.htm]
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ESTIMATED DATE
OF DELIVERY
(AGREED)
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Where a mother has different care providers though the course
of a pregnancy, there is a possibility that a differing value for
ESTIMATED DATE OF DELIVERY may be submitted by these
different providers.
Where the data provider does not know the ESTIMATED DATE
OF DELIVERY (eg. the mother only accessed care at the point
of labour and delivery), they should provide their best estimate
(eg. where the birth took place during the reporting period, data
providers should use the Baby’s Date of Birth).
The central data warehouse will deem all MAT001 groups
submitted for a mother, where the ESTIMATED DATE OF
DELIVERY in each group are 30 days or less apart, as being for
the same pregnancy.
Whilst this 30 day rule will enable reliable linkage in most
scenarios, it will not be viable if the ESTIMATED DATE OF
DELIVERY is unavailable and the mother delivers more than 30
days before or after the ESTIMATED DATE OF DELIVERY.
This is accepted as a limitation of the data set.
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PREGNANCY FIRST
CONTACT DATE
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NICE CG62 Antenatal Care defines pregnancy first contact as:
“The initial appointment where the mother first meets a
healthcare professional with a confirmed pregnancy. This
appointment includes referral into the maternity care pathway
and an opportunity for information giving so that the mother is
able to make informed decisions about her pregnancy care” 51.
The implementation of Maternity Matters52 gives women more
routes to access antenatal care. Consequently, it was not
feasible to adopt NICE’s definition of First Contact. The data set
development process has also identified other variations in the
way First Contact occurs.
First Contact for the purpose of the data set, is defined as:
The point at which a mother contacts a NHS care provider to
access antenatal/pregnancy care and gets referred to the
Maternity Care Pathway. The contact may be with a healthcare
professional, although not exclusively, and includes selfreferrals.
Examples of First Contact:

A mother making an appointment with a GP and the GP
referring the mother to maternity services. First Contact
will be the date the GP meets the mother

A mother self-referring to maternity services. For
example, by telephone, e-mail or letter. First Contact will
be the date the mother self-refers

A receptionist at a GP practice referring the mother to
maternity services (without the mother meeting a
healthcare professional). First Contact will be the date
the mother informs the receptionist of her pregnancy
CARE
PROFESSIONAL
TYPE CODE
(PREGNANCY
FIRST CONTACT)
In the case of self-referrals (to Maternity Services), this data
item will be null.
LAST MENSTRUAL
PERIOD DATE
This is the date of the first day of the last menstrual period (i.e.
the date on which the last menstrual period began).
51
England. NICE (Corrected Jun 2008) CG62 Antenatal Care: Full Guideline, London: RCOG Press, pp. xxviii
[http://guidance.NICE.org.uk/CG62]
52
Maternity Matters (2007)
[http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_074199.pdf]
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PHYSICAL
DISABILITY
STATUS
INDICATOR
(MOTHER AT
BOOKING)
V2.1
25/03/2013
This data item is set to [Y] Yes if the mother:


Has been diagnosed as physically disabled.
Perceives herself to be physically disabled.
The DDA 200553, defines ‘disability’ (under Section 1, part 1)
as:
“If the person has a physical or mental impairment which has a
substantial and long-term adverse effect on their ability to carry
out normal day-to-day activities”.
The definition of disability includes people with HIV, cancer and
multiple sclerosis, from the point of diagnosis, rather than from
the point when the condition has some adverse effect on their
ability to carry out normal day-to-day activities.54
Supplementary information related to specific elements of the
definition is available from Schedule 11 of DDA 199555.
FIRST LANGUAGE
ENGLISH
INDICATOR
(MOTHER AT
BOOKING)
Where local systems capture individual first languages, this can
be mapped to the MSDS values of [Y] Yes and [N] No
EMPLOYMENT
STATUS (MOTHER
AT BOOKING)
Whether or not the mother is in employment, as identified at the
Booking Appointment. ‘ZZ – not stated’ attribute should be used
only in the event that the mother is asked but declines to provide
a response.
SUPPORT STATUS
(MOTHER AT
BOOKING)
As identified at the Booking Appointment. This item is set to [Y]
Yes if the mother feels she is supported in pregnancy and when
looking after a baby, from partner, family or friends. ‘ZZ – not
stated’ attribute should be used only in the event that the mother
is asked but declines to provide a response.
EMPLOYMENT
STATUS (PARTNER
AT BOOKING)
Whether or not the partner of the mother (who may or may not
be the father) is in employment, as identified at the Booking
Appointment. ‘ZZ – not stated’ attribute should be used only in
the event that the mother is asked but declines to provide a
response.
This data item should only be completed when the partner is
known.
PREGNANCY
PREVIOUS
CAESAREAN
SECTIONS
53
The number of previous caesarean sections performed. This is
not the same as number of babies previously delivered via
caesarean.
Disability Discrimination Act 2005 [http://www.opsi.gov.uk/acts/acts2005/ukpga_20050013_en_1]
Update to ‘disable’ definition in DDA
[http://www.direct.gov.uk/en/DisabledPeople/RightsAndObligations/DisabilityRights/DG_4001069]
54
55
DDA 1995, Schedule 1[http://www.opsi.gov.uk/acts/acts1995/ukpga_19950050_en_10#sch1]
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PREGNANCY
TOTAL PREVIOUS
LIVE BIRTHS
The number of previous registrable live births by the mother.
PREGNANCY
TOTAL PREVIOUS
STILLBIRTHS
The number of registrable still births by the mother i.e. a birth
after a gestation of 24 weeks (168 days), or more, where a baby
shows no identifiable signs of life at delivery. Please note, up to
and including 30/9/92 the criteria was 28 weeks and not 24
weeks as above.
PREGNANCY
TOTAL PREVIOUS
LOSSES LESS
THAN 24 WEEKS
The recorded number of terminations and previous losses
before 24 weeks of pregnancy (i.e. less than 23 weeks and 6
days) for a woman.
SUBSTANCE USE
STATUS (MOTHER
AT BOOKING)
Examples of non-medicinal drugs or other unauthorised
substances are:






Cocaine
Crack
Heroin
Marijuana
Morphine
Solvents (e.g. glue, aerosol)
As the data item only looks at unauthorised substances; use or
abuse of tobacco, alcohol and prescribed medication is out of
scope.
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Maternity Services Data Set User Guidance
SMOKING STATUS
(MOTHER AT
BOOKING)
V2.1
25/03/2013
In regards to smoking status, systems should facilitate the
inclusion of corresponding booking appointment data items so
that the burden on data collection is minimised.
This data item captures the mother’s smoking status as
recorded at the initial booking appointment.
Where data providers capture the information in a different
format or at a lower level, then they should be mapped to an
appropriate value stated in the national code list.
Albeit in an aggregate form, an existing Information Standard,
Smoking and Pregnancy, captures the mother’s smoking status
at 3 stages:



12 months before pregnancy
Booking appointment
Delivery
The data submitted for the Smoking and Pregnancy DSCN is
independent of the data submitted for the MSDS, however, data
providers should ensure that both submissions are aligned. The
following mapping must be used:
Smoking and
Pregnancy
MSDS national code list
Yes
[1] Current smoker
No
[2] Ex-smoker
No
[3] Non-smoker - history unknown
No
[4] Never smoked
Don’t Know
[9] Unknown
CIGARETTES PER
DAY (MOTHER AT
BOOKING)
This is the number of CIGARETTES PER DAY smoked by the
mother, as identified at the APPOINTMENT DATE (FORMAL
ANTENATAL BOOKING).
WEEKLY ALCOHOL
UNITS (MOTHER AT
BOOKING)
Is the ALCOHOL WEEKLY UNITS reported by the mother at the
APPOINTMENT DATE (FORMAL ANTENATAL BOOKING).
STATUS OF FOLIC
ACID SUPPLEMENT
(MOTHER AT
BOOKING)
Whether a woman has been taking or intends to take folic acid
supplements.
Page 48 of 163
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Maternity Services Data Set User Guidance
MENTAL HEALTH
PREDICTION AND
DETECTION
INDICATOR
(MOTHER AT
BOOKING)
V2.1
25/03/2013
Whether the appropriate questions were asked to identify
mental health problems during the booking appointment. The
purpose of this data item is not to capture mental health issues.
NICE CG62 recommends that, at a mother’s first contact with
primary care, at her booking visit and postnatally (usually at 4 to
6 weeks and 3 to 4 months after the birth), healthcare
professionals (including midwives, obstetricians, health visitors
and GPs) should ask two questions to identify possible
depression:
1. During the past month, have you often been bothered by
feeling down, depressed or hopeless?
2. During the past month, have you often been bothered by
having little interest or pleasure in doing things?
A third question should be considered if the mother answers
‘yes’ to either of the initial questions.
3. Is this something you feel you need or want help with?56
PERSON WEIGHT
(MOTHER AT
BOOKING)
The unit of measurement is kilograms.
PERSON HEIGHT
(MOTHER AT
BOOKING)
The unit of measurement is metres.
COMPLEX SOCIAL
FACTORS
INDICATOR
(MOTHER AT
BOOKING)
(OPTIONAL)
Indicates if the mother is deemed to be subject to complex
social factors, as defined by NICE guidance (CG11057).
56
England. NICE (Corrected Jun 2008) CG62 Antenatal Care: Full Guideline, London: RCOG Press, pp. 119
[http://guidance.NICE.org.uk/CG62]
57
England. NICE (issued September 2010) CG110 Pregnancy and complex social factors: A model for service provision for
pregnant women with complex social factors [http://publications.nice.org.uk/pregnancy-and-complex-social-factors-cg110]
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5.3.3. MAT102 Complicating Medical Diagnosis at Booking
MAT102 Complicating Medical Diagnosis at Booking
Description
This group collects information on past medical diagnoses, as captured or made
available at the booking appointment.
Group Level Validation and Repeating Rules
These rules are fully described in the appropriate section for this group within the
document Maternity Data Set Technical Output Specification.
Additional Notes on Data Items
Data Item Name
Additional Notes
LOCAL PATIENT
IDENTIFIER
(MOTHER)
This is the unique system identifier that identifies the mother.
This is the primary key that enables groups of data to be joined
together. As such this is a mandated item and the record will be
rejected if it is not included within this group.
Where multiple systems are used it is acceptable to include a
prefix to the Local Patient Identifier, which relates to the system.
The prefix enables each identifier to remains truly unique for all
submissions from an organisation.
Duplicate Local Patient Identifiers within the same submission
file will cause the entire file to be rejected. Duplicate Local
Patient Identifiers across multiple submission files will cause
both records to be rejected even if it is unique within each
submission file.
APPOINTMENT
DATE (FORMAL
ANTENATAL
BOOKING)
Referred to as the Booking Appointment, the date on which the
assessment for health and social care needs, risks and choices
and arrangements made for antenatal care as part of the
pregnancy episode was completed.
This is the primary key that enables groups of data to be joined
together. As such this is a mandated item and the record will be
rejected if it is not included within this group.
MATERNITY
COMPLICATING
MEDICAL
DIAGNOSIS TYPE
(MOTHER AT
BOOKING)
If a data provider uses locally defined value codes then these
need to be mapped to the relevant national code in the data set.
[01] Hypertension is defined as:
A single diastolic blood pressure of 110 mmHg or any
consecutive readings of 90 mmHg on more than one occasion
at least 4 hours apart58
58
England. NICE (Corrected Jun 2008) CG62 Antenatal Care: Full Guideline, London: RCOG Press, pp. 218
[http://www.nice.org.uk/nicemedia/live/11947/40145/40145.pdf]
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V2.1
25/03/2013
5.3.4. MAT103 Previous Complicating Obstetric Diagnoses at Booking
MAT103 Previous Complicating Obstetric Diagnoses at Booking
Description
This group collects information on obstetric conditions diagnosed in previous
pregnancies, as captured or made available at the booking appointment.
The diagnoses do not need to be linked to specific pregnancies nor do they need to be
repeated if the same diagnosis has occurred in several pregnancies.
Group Level Validation and Repeating Rules
These rules are fully described in the appropriate section for this group within the
document Maternity Data Set Technical Output Specification.
Additional Notes on Data Items
Data Item Name
Additional Notes
LOCAL PATIENT
IDENTIFIER
(MOTHER)
This is the unique system identifier that identifies the mother.
This is the primary key that enables groups of data to be joined
together. As such this is a mandated item and the record will be
rejected if it is not included within this group.
Where multiple systems are used it is acceptable to include a
prefix to the Local Patient Identifier, which relates to the system.
The prefix enables each identifier to remains truly unique for all
submissions from an organisation.
Duplicate Local Patient Identifiers within the same submission
file will cause the entire file to be rejected. Duplicate Local
Patient Identifiers across multiple submission files will cause
both records to be rejected even if it is unique within each
submission file.
APPOINTMENT
DATE (FORMAL
ANTENATAL
BOOKING)
Referred to as the Booking Appointment, the date on which the
assessment for health and social care needs, risks and choices
and arrangements made for antenatal care as part of the
pregnancy episode was completed.
This is the primary key that enables groups of data to be joined
together. As such this is a mandated item and the record will be
rejected if it is not included within this group.
Page 51 of 163
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Maternity Services Data Set User Guidance
MATERNITY
PREVIOUS
COMPLICATING
OBSTETRIC
DIAGNOSIS TYPE
(MOTHER AT
BOOKING)
V2.1
25/03/2013
If a data provider uses locally defined value codes then these
need to be mapped to the relevant national code in the data set.
Definitions of national codes below:
National Code
Definition
01 Severe preeclampsia requiring
pre-term birth
Severe hypertension (a diastolic blood
pressure ≥ 110 mmHg on two
occasions or systolic blood pressure ≥
170 mmHg on two occasions) and
significant proteinuria (at least 1
g/litre)59.
02 Haemolytic
anaemia, Elevated
Liver enzymes and
Low Platelet count
(HELLP)
‘HELLP’ is defined as a combined liver
and blood clotting disorder which is a
complication of pre-eclampsia60.
03 Eclampsia
‘Eclampsia’
is
defined
as
the
occurrence of one or more convulsions
superimposed on pre-eclampsia62.
‘Pre-eclampsia’
is
defined
as
pregnancy-induced hypertension in
association with proteinuria (> 0.3 g in
24 hours) ± oedema and virtually any
organ system may be affected61.
‘Pre-eclampsia’
is
defined
as
pregnancy-induced hypertension in
association with proteinuria (> 0.3 g in
24 hours) ± oedema and virtually any
organ system may be affected63.
04 Puerperal
psychosis
Serious mental illness, developing in a
mother shortly after birth. There are 3
main illnesses that happen during this
time:
 Mania
 Depression
 Schizophrenia64
05 Liver cholestasis Multifactorial condition of pregnancy
of pregnancy
characterised by intense pruritus
(severe itching) in the absence of a skin
rash, with abnormal liver function tests
(LFTs), neither of which have an
alternative cause and both of which
remit following delivery65.
Also
referred
cholestasis’.
06 Gestational
diabetes mellitus
59
to
as
‘obstetric
Carbohydrate intolerance resulting in
hyperglycaemia of variable severity with
onset or first recognition during
pregnancy and with a return to normal
after birth66.
England. RCOG (Mar 2006) Green-top 10(A): The Management of severe pre-eclampsia/eclampsia. 1st ed. pp. 1
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[http://www.rcog.org.uk/files/rcog-corp/uploaded-files/GT10aManagementPreeclampsia2006.pdf]
RCOG, Medical terms explained, HELLP syndrome – [http://www.rcog.org.uk/womens-health/patientinformation/medical-terms-explained]
60
RCOG, Medical terms explained, HELLP syndrome – [http://www.rcog.org.uk/womens-health/patientinformation/medical-terms-explained]
61
62
England. RCOG (Mar 2006) Green-top 10(A): The Management of severe pre-eclampsia/eclampsia. 1st ed. pp. 1
[http://www.rcog.org.uk/files/rcog-corp/uploaded-files/GT10aManagementPreeclampsia2006.pdf]
63
England. RCOG (Mar 2006) Green-top 10(A): The Management of severe pre-eclampsia/eclampsia. 1st ed. pp. 1
[http://www.rcog.org.uk/files/rcog-corp/uploaded-files/GT10aManagementPreeclampsia2006.pdf]
RCPSych, Mental illness after childbirth –
[http://www.rcpsych.ac.uk/mentalhealthinfoforall/problems/postnatalmentalhealth/afterchildbirth.aspx]
64
65
England. RCOG (Jan 2006) Green -top 43: Obstetric cholestasis. 1st ed. pp. 1 [http://www.rcog.org.uk/files/rcogcorp/uploaded-files/GT43ObstetricCholestasis2006.pdf]
66
England. NICE (Corrected Jun 2008) CG62 Antenatal Care: Full Guideline, London: RCOG Press, pp. 205
[http://www.nice.org.uk/nicemedia/live/11947/40145/40145.pdf]
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07 Gestational
hypertension
V2.1
25/03/2013
‘Gestational hypertension’ is defined as
a new hypertension presenting after 20
weeks without significant proteinuria67.
‘Hypertension’ is defined as a single
diastolic blood pressure of 110 mmHg
or any consecutive readings of 90
mmHg on more than one occasion at
least 4 hours apart68.
‘Proteinuria’ is defined as a 300 mg
excretion of protein in a 24 hour
collected urine, two clean catch urine
specimens at least 4 hours apart with
2+ proteinuria by dipstick69.
08 Gestational
proteinuria
A 300 mg excretion of protein in a 24
hour collected urine, two clean catch
urine specimens at least 4 hours apart
with 2+ proteinuria by dipstick.70
09 Antepartum
haemorrhage
Bleeding from the genital tract after the
24th week of pregnancy until the birth
of the baby.71
10 Postpartum
haemorrhage requiring additional
treatment or
transfusion
‘Primary Postpartum haemorrhage
(PPH)’ is defined as a loss of 500 ml or
more of blood from the genital tract
within 24 hours of the birth of a baby72.
‘Secondary postpartum haemorrhage
(PPH)’ is defined as abnormal or
excessive bleeding from the birth canal
between 24 hours and 12 weeks
postnatally73. For the purpose of the
MSDS, secondary postpartum
haemorrhage will only be relevant until
the point of discharge from maternity
services.
England. NICE (Feb 2010) Hypertension in pregnancy, The management of hypertensive disorders during pregnancy –
Full Guideline, pp pp. 205 [http://www.nice.org.uk/guidance/index.jsp?action=download&o=47351]
67
68
England. NICE (Corrected Jun 2008) CG62 Antenatal Care: Full Guideline, London: RCOG Press, pp. 218
[http://www.nice.org.uk/nicemedia/live/11947/40145/40145.pdf]
69
England. NICE (Corrected Jun 2008) CG62 Antenatal Care: Full Guideline, London: RCOG Press, pp. 218
[http://www.nice.org.uk/nicemedia/live/11947/40145/40145.pdf]
70
England. NICE (Corrected Jun 2008) CG62 Antenatal Care: Full Guideline, London: RCOG Press, pp. 218
[http://www.nice.org.uk/nicemedia/live/11947/40145/40145.pdf]
71
Oxford concise colour medical dictionary, New 3rd edition, Oxford University Press, 2002
72
England. RCOG Green-top Guideline No. 52: Prevention and management of postpartum haemorrhage. 1st ed. pp. 1
(Mar 2009) [http://www.rcog.org.uk/files/rcog-corp/Green-top52PostpartumHaemorrhage.pdf]
73
England. RCOG Green-top Guideline No. 52: Prevention and management of postpartum haemorrhage. 1st ed. pp. 1
(Mar 2009) [http://www.rcog.org.uk/files/rcog-corp/Green-top52PostpartumHaemorrhage.pdf]
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11 Feto-maternal
haemorrhage
Fetal blood entering the maternal
circulation74.
12 Antenatal/
postpartum
thromboembolic
disorder
‘Thromboembolic disorder’ is defined
using definitions of ‘thrombus’ and
‘embolus’
‘Thrombus’ is defined as a condition in
which a blood changes from a liquid to
a solid state and produces a blood clot
Note – the definition of thrombus is
based on the ‘thrombosis’ definition75.
‘Embolus’ is defined as blood clot that
is carried by the blood from one point in
the circulation to lodge at another
point76.
Note the cited definition of ‘embolus’
refers to a small number of materials,
one of which being blood clot. For the
purpose of this data set, only the blood
clot element of the full definition is
being used.
‘Antepartum’ is defined as the period
following conception to before the start
of labour.
‘Postpartum’ (as pertaining to the
mother) is defined as the period
between childbirth and a minimum of
28 days postnatally. For the purpose
of the MSDS, postpartum will only refer
to the point of discharge from maternity
services.
74
England. NICE (Aug 2008) TA156: Routine antenatal anti-D prophylaxis for women who are rhesus D negative, pp. 4
[http://www.nice.org.uk/nicemedia/live/12047/41690/41690.pdf]
75
Oxford concise colour medical dictionary, new 3 rd edition, Oxford University Press, 2002
76
Oxford concise colour medical dictionary, new 3 rd edition, Oxford University Press, 2002
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13 Placental
abruption
The premature separation of the
placenta from the uterus which results
in bleeding during the pregnancy77.
14 Uterine rupture
A full-thickness separation of the
uterine wall and the overlying serosa78.
15 Retained
placenta requiring
manual removal in
theatre
‘Retained placenta’ is defined as when
the placenta has not been delivered
within 30 minutes of birth when the
third stage is actively managed, and
longer than 1 hour when physiologically
managed, without signs of postpartum
haemorrhage (PPH) or maternal
collapse79.
‘Manual removal’ is defined as a hand
being inserted into the vagina and into
the uterus to detach the placenta from
the uterine wall.
16 Caesarean
section
An operation to deliver the baby by
cutting through the wall of the abdomen
and the uterus. It may be done as a
planned (elective) or an emergency
procedure80.
17 Extensive
vaginal, cervical or
third or fourth
degree perineal
trauma
‘Cervical trauma’ is defined as a partial
disruption of the cervix of the uterus
A ‘third degree perineal tear’ (also
referred to as ‘third degree tear’) is
defined as a partial or complete
disruption of the anal sphincter
muscles, which may involve either or
both the external (EAS) and internal
anal sphincter (IAS) muscles81.
A ‘fourth degree perineal tear’ (also
referred to as ‘fourth degree tear’) is
defined as a disruption of the anal
sphincter muscles with a breach of the
rectal mucosa82.
18 Amniotic Fluid
Embolism
Amniotic fluid embolism is a rare
complication of pregnancy, where
amniotic fluid, fetal cells, hair or other
debris enters the mother's blood
stream via the placental bed of the
uterus and triggers an allergic reaction.
This is distinct from a blood embolism.
77
England. RCOG, BJOG release: New study reveals an association between later placental problems in mums (May
2007) [http://www.rcog.org.uk/news/bjog-release-new-study-reveals-association-between-later-placental-problems-mums]
78
Uterine rupture in pregnancy: eMedicine, definition [http://emedicine.medscape.com/article/275854-overview]
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25/03/2013
5.3.5. MAT104 Family History Diagnosis at Booking
MAT104 Family History Diagnosis at Booking
Description
This group collects information on the baby’s maternal and paternal medical family
history (but only where the relative is a blood relative), as captured or made available at
the booking appointment.
The diagnoses do not need to be linked to specific relatives nor do they need to be
repeated if the same diagnosis has occurred in several relatives.
Blood relatives included:














Mother
Father
Sister
Brother
Half Sister
Half Brother
Paternal Grandparent
Maternal Grandparent
Paternal Great-Grandparent
Maternal Great-Grandparent
Aunt
Uncle
First Cousin
Nephew/Niece
Group Level Validation and Repeating Rules
These rules are fully described in the appropriate section for this group within the
document Maternity Data Set Technical Output Specification.
Additional Notes on Data Items
Data Item Name
Additional Notes
79
England. NICE (Corrected Jun 2008) CG55 Intrapartum Care: Full Guideline, London: RCOG Press, pp. 246
[http://www.nice.org.uk/nicemedia/live/11837/36275/36275.pdf]
80
RCOG, Medical terms explained, Caesarean section [http://www.rcog.org.uk/womens-health/patient-information/medicalterms-explained]
81
England. RCOG (Mar 2007) Green-top Guideline No. 29: The management of third and fourth degree perineal tears. 2nd
ed. pp. 1 [http://www.rcog.org.uk/files/rcog-corp/uploaded-files/GT29ManagementThirdFourthDegreeTears2007.pdf]
82
England. RCOG (Mar 2007) Green-top Guideline No. 29: The management of third and fourth degree perineal tears. 2nd
ed. pp. 1 [http://www.rcog.org.uk/files/rcog-corp/uploaded-files/GT29ManagementThirdFourthDegreeTears2007.pdf]
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LOCAL PATIENT
IDENTIFIER
(MOTHER)
V2.1
25/03/2013
This is the unique system identifier that identifies the mother.
This is the primary key that enables groups of data to be joined
together. As such this is a mandated item and the record will be
rejected if it is not included within this group.
Where multiple systems are used it is acceptable to include a
prefix to the Local Patient Identifier, which relates to the system.
The prefix enables each identifier to remains truly unique for all
submissions from an organisation.
Duplicate Local Patient Identifiers within the same submission
file will cause the entire file to be rejected. Duplicate Local
Patient Identifiers across multiple submission files will cause
both records to be rejected even if it is unique within each
submission file.
APPOINTMENT
DATE (FORMAL
ANTENATAL
BOOKING)
Referred to as the Booking Appointment, the date on which the
assessment for health and social care needs, risks and choices
and arrangements made for antenatal care as part of the
pregnancy episode was completed.
This is the primary key that enables groups of data to be joined
together. As such this is a mandated item and the record will be
rejected if it is not included within this group
MATERNITY
FAMILY HISTORY
DIAGNOSIS TYPE
(AT BOOKING)
Page 58 of 163
If a data provider uses locally defined value codes then these
need to be mapped to the relevant national code in the data set.
Copyright ©2013 Health and Social Care Information Centre
Maternity Services Data Set User Guidance
V2.1
25/03/2013
5.3.6. MAT112 Dating Scan Procedure
MAT112 Dating Scan Procedure
Description
This group collects the information captured when a dating scan is performed.
Whilst this scan is generally offered at the booking appointment and performed between
10 weeks + 0 days and 13 weeks + 6 days83, it can be undertaken at any time during the
pregnancy.
The data set does not record the method by which gestational length was calculated.
There are insufficient data items to assess the type of method.
Where the dating scan assessment is performed during the fetal anomaly scan, the data
provider will capture the same date for both data set groups. The matching values of
procedure date/time across the two groups will indicate that a ‘combined’ dating-fetal
anomaly scan was undertaken.
The dating scan may be performed by the radiology department, maternity services or
fetal medicine units. Therefore, the data relating to the scan may be captured from
either radiology, maternity or fetal medicine systems.
Group Level Validation and Repeating Rules
These rules are fully described in the appropriate section for this group within the
document Maternity Data Set Technical Output Specification.
Additional Notes on Data Items
Data Item Name
Additional Notes
LOCAL PATIENT
IDENTIFIER
(MOTHER)
This is the unique system identifier that identifies the mother.
This is the primary key that enables groups of data to be joined
together. As such this is a mandated item and the record will be
rejected if it is not included within this group.
Where multiple systems are used it is acceptable to include a
prefix to the Local Patient Identifier, which relates to the system.
The prefix enables each identifier to remains truly unique for all
submissions from an organisation.
Duplicate Local Patient Identifiers within the same submission
file will cause the entire file to be rejected. Duplicate Local
Patient Identifiers across multiple submission files will cause
both records to be rejected even if it is unique within each
submission file.
ACTIVITY OFFER
DATE
The date that the dating scan activity was offered. This item is
not mandated, but if the Activity Offer Date and Procedure Date
are both blank (or the Offer Date is after the Procedure Date or
before the Booking Appointment Date from MAT101), then the
group will be rejected.
83
England. NICE (Corrected Jun 2008), CG62 Antenatal Care: Full Guideline, London, RCOG Press, pp. 77
[http://www.nice.org.uk/nicemedia/live/11947/40145/40145.pdf]
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V2.1
25/03/2013
OFFER STATUS
(DATING
ULTRASOUND
SCAN)
Whether or not the dating scan was offered, and the subsequent
response to the offer.
GESTATION
(DATING
ULTRASOUND
SCAN)
The gestation length in days84 of the fetus(es) as measured by
the dating ultrasound scan.
NUMBER OF
FETUSES (DATING
ULTRASOUND
SCAN)
The number of Fetuses counted during an Ultrasound Scan In
Pregnancy within a particular Pregnancy Episode.
ABNORMALITY
DETECTED
(DATING
ULTRASOUND
SCAN)
If a data provider uses locally defined value codes then these
need to be mapped to the relevant national code in the data set.
Multiple abnormalities
This data item is only to be submitted once, even in the case of
a fetus having multiple abnormalities or two or more fetuses (of
a multi-fetus pregnancy) each having abnormalities.
Combined dating-fetal anomaly scan
Where dating scan assessments are undertaken for the first
time in conjunction with a fetal anomaly scan, any observed
abnormality will be captured in the fetal anomaly group (under
data item INVESTIGATION RESULT (ULTRASOUND FETAL
ANOMALY SCREENING). This data item would, consequently,
be null.
NB. This data item is not related to Down’s Syndrome
Screening.
84
NHS Data Dictionary
[http://www.datadictionary.nhs.uk/data_dictionary/nhs_business_definitions/g/gestation_length_in_days_de.asp?shownav=
1]
Page 60 of 163
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Maternity Services Data Set User Guidance
V2.1
25/03/2013
5.3.7. MAT201 Mother's ABO Blood Group and Rhesus Test Results
MAT201 Mother's ABO Blood Group and Rhesus Test Results
Description
Routinely, blood samples for infectious diseases and inherited blood disorders are
offered and taken at the booking appointment. However, blood tests could be
undertaken at any time during the pregnancy.
According to NICE CG62 Antenatal Care, blood samples should ideally be taken within
10 weeks gestation85. However, it may be that, for whatever reason, the blood samples
are taken later and possibly even just before the onset of labour. Irrespective of timing, if
a data provider takes blood samples the appropriate information will be captured in this
section. At the reporting stage, the ‘blood test sample date’ data item will indicate how
late the tests were undertaken.
Group Level Validation and Repeating Rules
These rules are fully described in the appropriate section for this group within the
document Maternity Data Set Technical Output Specification.
Additional Notes on Data Items
Data Item Name
Additional Notes
LOCAL PATIENT
IDENTIFIER
(MOTHER)
This is the unique system identifier that identifies the mother.
This is the primary key that enables groups of data to be joined
together. As such this is a mandated item and the record will be
rejected if it is not included within this group.
Where multiple systems are used it is acceptable to include a
prefix to the Local Patient Identifier, which relates to the system.
The prefix enables each identifier to remains truly unique for all
submissions from an organisation.
Duplicate Local Patient Identifiers within the same submission
file will cause the entire file to be rejected. Duplicate Local
Patient Identifiers across multiple submission files will cause
both records to be rejected even if it is unique within each
submission file.
BLOOD TEST
SAMPLE DATE
(MOTHER BLOOD
GROUP AND
RHESUS STATUS)
Local systems may have been developed in such a manner that
the blood test sample date is only captured once. In this case,
this single date needs to be cascaded to all the groups relating
to the blood test sample.
BLOOD GROUP
(MOTHER)
Information about less common non-ABO blood groups (e.g.
Kell) are outside the scope of the MSDS.
85
England. NICE (Corrected Jun 2008) CG62 Antenatal Care: Full Guideline, London: RCOG Press, pp. 78
[http://www.nice.org.uk/nicemedia/live/11947/40145/40145.pdf]
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Maternity Services Data Set User Guidance
RHESUS GROUP
(MOTHER)
V2.1
25/03/2013
RhD–positive relates to a mother who possesses the D antigen.
RhD-negative relates to a mother who does not possess the D
antigen.
Information about less common rhesus blood groups (e.g. RhC)
are outside the scope of the MSDS.
INVESTIGATION
RESULT (MOTHER
RHESUS
ANTIBODIES)
Page 62 of 163
This data item is only relevant for a rhesus negative mother (as
identified via data item RHESUS GROUP (MOTHER)).
‘Sensitised’ refers to a rhesus negative mother who possess
anti-D antibodies. ‘Non-sensitised’ refers to a mother who does
not possess anti-D antibodies.
Copyright ©2013 Health and Social Care Information Centre
Maternity Services Data Set User Guidance
V2.1
25/03/2013
5.3.8. MAT203 Mother's Rubella Susceptibility Test
MAT203 Mother's Rubella Susceptibility Test
Description
Routinely, blood samples for infectious diseases and inherited blood disorders are
offered and taken at the booking appointment. However, blood tests could be
undertaken at any time during the pregnancy.
According to NICE CG62 Antenatal Care, a mother should be offered screening for
typical red cell antibodies (which included rhesus antibodies) early in pregnancy and at
28 weeks86. This data set does not capture any information on 28 week screening.
According to NICE CG62 Antenatal Care, blood samples should ideally be taken within
10 weeks gestation87. However, it may be that, for whatever reason, the blood samples
are taken later and possibly even just before the onset of labour. Irrespective of timing, if
a data provider takes blood samples the appropriate information will be captured in this
section. At the reporting stage, the ‘blood test sample date’ data item will indicate how
late the tests were undertaken.
Group Level Validation and Repeating Rules
These rules are fully described in the appropriate section for this group within the
document Maternity Data Set Technical Output Specification.
Additional Notes on Data Items
Data Item Name
Additional Notes
LOCAL PATIENT
IDENTIFIER
(MOTHER)
This is the unique system identifier that identifies the mother.
This is the primary key that enables groups of data to be joined
together. As such this is a mandated item and the record will be
rejected if it is not included within this group.
Where multiple systems are used it is acceptable to include a
prefix to the Local Patient Identifier, which relates to the system.
The prefix enables each identifier to remains truly unique for all
submissions from an organisation.
Duplicate Local Patient Identifiers within the same submission
file will cause the entire file to be rejected. Duplicate Local
Patient Identifiers across multiple submission files will cause
both records to be rejected even if it is unique within each
submission file.
ACTIVITY OFFER
DATE
The date that the blood test was offered. This item is not
mandated, but if the Activity Offer Date and Blood Test Sample
Date are both blank (or the Offer Date is after the Blood Test
Sample Date or before the Booking Appointment Date from
MAT101), then the group will be rejected.
86
England. NICE (Corrected Jun 2008) CG62 Antenatal Care: Full Guideline, London: RCOG Press, pp. 78-79
[http://www.nice.org.uk/nicemedia/live/11947/40145/40145.pdf]
87
England. NICE (Corrected Jun 2008) CG62 Antenatal Care: Full Guideline, London: RCOG Press, pp. 78-79
[http://www.nice.org.uk/nicemedia/live/11947/40145/40145.pdf]
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Maternity Services Data Set User Guidance
OFFER STATUS
(SCREENING
MOTHER RUBELLA
SUSCEPTIBILITY)
V2.1
25/03/2013
[01] Offered and undecided is a transient value, which will, in
most cases, be superseded by [02] Offered and declined or [03]
Offered and accepted.
The only time where [01] Offered and undecided should be
submitted is where a mother considers the screening offer but is
unable to confirm how she wishes to progress before the
submission window closes for the reporting period that contains
the Date of Offer. (ie. This is the last chance for the data
provider to submit this group before it will be rejected due to
being for the wrong reporting period).
If she subsequently confirms her wishes, then the group should
be resent with the Date of Offer set to the date the mother made
the decision.
BLOOD TEST
SAMPLE DATE
(SCREENING
MOTHER RUBELLA
SUSCEPTIBILITY)
Local systems may have been developed in such a manner that
the blood test sample date is only captured once. In this case,
this single date needs to be cascaded to all the groups relating
to the blood test sample.
INVESTIGATION
RESULT
(SCREENING
MOTHER RUBELLA
SUSCEPTIBILITY)
For clinical management purposes, [02] Rubella susceptible
(<10 IU/ml) will indicate that the mother is in need of MMR
vaccination, post-delivery.
[03] Test process incomplete should be used in any instance
where a sample has been taken and the testing process for that
sample could not be completed (which identifies a failure or
delay in the screening process). This may be because


Page 64 of 163
The sample was lost in transit.
The sample received at the laboratory was inadequate.
Copyright ©2013 Health and Social Care Information Centre
Maternity Services Data Set User Guidance
V2.1
25/03/2013
5.3.9. MAT205 Mother's Hepatitis B Screening Test
MAT205 Mother's Hepatitis B Screening Test
Description
Routinely, blood samples for infectious diseases and inherited blood disorders are
offered and taken at the booking appointment. However, blood tests could be
undertaken at any time during the pregnancy.
According to NICE CG62 Antenatal Care, blood samples should ideally be taken within
10 weeks gestation88. However, it may be that, for whatever reason, the blood samples
are taken later and possibly even just before the onset of labour. Irrespective of timing, if
a data provider takes blood samples the appropriate information will be captured in this
section. At the reporting stage, the ‘blood test sample date’ data item will indicate how
late the tests were undertaken.
This group should be repeated for each blood sample and associated result. However,
data providers may only submit data on the final sample which provides the conclusive
result.
Group Level Validation and Repeating Rules
These rules are fully described in the appropriate section for this group within the
document Maternity Data Set Technical Output Specification.
Additional Notes on Data Items
Data Item Name
Additional Notes
LOCAL PATIENT
IDENTIFIER
(MOTHER)
This is the unique system identifier that identifies the mother.
This is the primary key that enables groups of data to be joined
together. As such this is a mandated item and the record will be
rejected if it is not included within this group.
Where multiple systems are used it is acceptable to include a
prefix to the Local Patient Identifier, which relates to the system.
The prefix enables each identifier to remains truly unique for all
submissions from an organisation.
Duplicate Local Patient Identifiers within the same submission
file will cause the entire file to be rejected. Duplicate Local
Patient Identifiers across multiple submission files will cause
both records to be rejected even if it is unique within each
submission file.
ACTIVITY OFFER
DATE
The date that the blood test was offered. This item is not
mandated, but if the Activity Offer Date and Blood Test Sample
Date are both blank (or the Offer Date is after the Blood Test
Sample Date or before the Booking Appointment Date from
MAT101), then the group will be rejected.
88
England. NICE (Corrected Jun 2008) CG62 Antenatal Care: Full Guideline, London: RCOG Press, pp. 78
[http://www.nice.org.uk/nicemedia/live/11947/40145/40145.pdf]
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Maternity Services Data Set User Guidance
OFFER STATUS
(SCREENING
MOTHER
HEPATITIS B)
V2.1
25/03/2013
[01] Offered and undecided is a transient value, which will, in
most cases, be superseded by [02] Offered and declined or [03]
Offered and accepted.
The only time where [01] Offered and undecided should be
submitted is where a mother considers the screening offer but is
unable to confirm how she wishes to progress before the
submission window closes for the reporting period that contains
the Date of Offer (i.e. this is the last chance for the data provider
to submit this group before it will be rejected due to being for the
wrong reporting period).
If she subsequently confirms her wishes, then the group should
be resent with the Date of Offer set to the date the mother made
the decision.
BLOOD TEST
SAMPLE DATE
(SCREENING
MOTHER
HEPATITIS B)
Local systems may have been developed in such a manner that
the blood test sample date is only captured once. In this case,
this single date needs to be cascaded to all the groups relating
to the blood test sample.
INVESTIGATION
RESULT
(SCREENING
MOTHER
HEPATITIS B)
[03] Test process incomplete should be used in any instance
where a sample has been taken and the testing process for that
sample could not be completed (which identifies a failure or
delay in the screening process). This may be because
Page 66 of 163


The sample was lost in transit; or
The sample received at the laboratory was inadequate.
Copyright ©2013 Health and Social Care Information Centre
Maternity Services Data Set User Guidance
5.3.10.
V2.1
25/03/2013
MAT210 Mother's Asymptomatic Bacteriuria Screening Offer
MAT210 Mother's Asymptomatic Bacteriuria Screening Offer
Description
Routinely, screening for infectious diseases and inherited blood disorders are offered
and taken at the booking appointment. However, Asymptomatic Bacteriuria Screening
tests could be undertaken at any time during the pregnancy.
Group Level Validation and Repeating Rules
These rules are fully described in the appropriate section for this group within the
document Maternity Data Set Technical Output Specification.
Additional Notes on Data Items
Data Item Name
Additional Notes
LOCAL PATIENT
IDENTIFIER
(MOTHER)
This is the unique system identifier that identifies the mother.
This is the primary key that enables groups of data to be joined
together. As such this is a mandated item and the record will be
rejected if it is not included within this group.
Where multiple systems are used it is acceptable to include a
prefix to the Local Patient Identifier, which relates to the system.
The prefix enables each identifier to remains truly unique for all
submissions from an organisation.
Duplicate Local Patient Identifiers within the same submission
file will cause the entire file to be rejected. Duplicate Local
Patient Identifiers across multiple submission files will cause
both records to be rejected even if it is unique within each
submission file.
ACTIVITY OFFER
DATE
The date that the test was offered. This item is not mandated,
but if the Offer Date is before the Booking Appointment Date
(from MAT101) or not within the reporting period, then the group
will be rejected.
OFFER STATUS
(SCREENING
MOTHER
ASYMPTOMATIC
BACTERIURIA)
[01] Offered and undecided is a transient value, which will, in
most cases, be superseded by [02] Offered and declined or [03]
Offered and accepted.
The only time where [01] Offered and undecided should be
submitted is where a mother considers the screening offer but is
unable to confirm how she wishes to progress before the
submission window closes for the reporting period that contains
the Date of Offer (i.e. this is the last chance for the data provider
to submit this group before it will be rejected due to being for the
wrong reporting period).
If she subsequently confirms her wishes, then the group should
be resent with the Date of Offer set to the date the mother made
the decision.
Page 67 of 163
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Maternity Services Data Set User Guidance
5.3.11.
V2.1
25/03/2013
MAT211 Mother's Haemoglobinopathy Screening Test
MAT211 Mother's Haemoglobinopathy Screening Test
Description
Routinely, blood samples for infectious diseases and inherited blood disorders are
offered and taken at the booking appointment. However, blood tests could be
undertaken at any time during the pregnancy.
According to NICE CG62 Antenatal Care, blood samples should ideally be taken within
10 weeks gestation89. However, it may be that, for whatever reason, the blood samples
are taken later and possibly even just before the onset of labour. Irrespective of timing, if
a data provider takes blood samples the appropriate information will be captured in this
section. At the reporting stage, the ‘blood test sample date’ data item will indicate how
late the tests were undertaken.
This group only relates to blood tests for SCD, thalassaemia and other haemoglobin
variants. Data items related to the offer and outcome of the family origin questionnaire
are outside the scope of the MSDS.
Background
The NHS Sickle cell and thalassaemia screening programme90 has defined screening
standards on a mother’s residency91. Where a mother resides in a:


High prevalence area for sickle cell disease, the mother should be offered a
blood test for sickle cell disease (SCD), thalassaemia and other haemoglobin
variants.
Low prevalence area for SCD, the mother should be offered a blood test for
thalassaemia, and a family origin questionnaire to identify the risk of SCD & other
haemoglobin variants.
A mother in a low prevalence area is offered a subsequent blood test for SCD and other
haemoglobin variants where:


A mother identifies an origin outside UK (White), Northern Europe (White) or a
country where its origins lie in Northern Europe (White)92; Or
The thalassaemia blood test indicates an abnormality
The standards also state that a mother, from a low prevalence area, is eligible to request
a blood test for sickle cell disease, thalassaemia and other haemoglobin variants93,
irrespective of the local screening protocol.
Group Level Validation and Repeating Rules
89
England. NICE (Corrected Jun 2008) CG62 Antenatal Care: Full Guideline, London: RCOG Press, pp. 78
[http://www.nice.org.uk/nicemedia/live/11947/40145/40145.pdf]
90
NHS Sickle cell and thalassaemia screening programme home page – [http://sct.screening.nhs.uk/]
Standards for the linked antenatal and newborn screening programme –
[http://sct.screening.nhs.uk/cms.php?folder=2493]
91
NHS Sickle cell and thalassaemia screening programme, Family Origin Questionnaire, Page 2 –
[http://sct.screening.nhs.uk/cms.php?folder=2461]
92
93
Screening tests for you and your baby (2010), page 7 [http://www.screening.nhs.uk/annbpublications]
Page 68 of 163
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V2.1
25/03/2013
These rules are fully described in the appropriate section for this group within the
document Maternity Data Set Technical Output Specification.
Additional Notes on Data Items
Data Item Name
Additional Notes
LOCAL PATIENT
IDENTIFIER
(MOTHER)
This is the unique system identifier that identifies the mother.
This is the primary key that enables groups of data to be joined
together. As such this is a mandated item and the record will be
rejected if it is not included within this group.
Where multiple systems are used it is acceptable to include a
prefix to the Local Patient Identifier, which relates to the system.
The prefix enables each identifier to remains truly unique for all
submissions from an organisation.
Duplicate Local Patient Identifiers within the same submission
file will cause the entire file to be rejected. Duplicate Local
Patient Identifiers across multiple submission files will cause
both records to be rejected even if it is unique within each
submission file.
ACTIVITY OFFER
DATE
The date that the blood test was offered. This item is not
mandated, but if the Activity Offer Date and Blood Test Sample
Date are both blank (or the Offer Date is after the Blood Test
Sample Date or before the Booking Appointment Date from
MAT101), then the group will be rejected.
OFFER STATUS
(SCREENING
MOTHER
HAEMOGLOBINOPA
THY)
[01] Offered and undecided is a transient value, which will, in
most cases, be superseded by [02] Offered and declined or [03]
Offered and accepted.
The only time where [01] Offered and undecided should be
submitted is where a mother considers the screening offer but is
unable to confirm how she wishes to progress before the
submission window closes for the reporting period that contains
the Date of Offer (i.e. this is the last chance for the data provider
to submit this group before it will be rejected due to being for the
wrong reporting period).
If she subsequently confirms her wishes, then the group should
be resent with the Date of Offer set to the date the mother made
the decision.
BLOOD TEST
SAMPLE DATE
(SCREENING
MOTHER
HAEMOGLOBINOPA
THY)
Page 69 of 163
Local systems may have been developed in such a manner that
the blood test sample date is only captured once. In this case,
this single date needs to be cascaded to all the groups relating
to the blood test sample.
Copyright ©2013 Health and Social Care Information Centre
Maternity Services Data Set User Guidance
INVESTIGATION
RESULT
(SCREENING
MOTHER
HAEMOGLOBINOPA
THY)
V2.1
25/03/2013
Detailed description of each national code listed below:
National Code
Definition
00 Not indicated
Testing not indicated by indices or FOQ
This value is only relevant for a mother
in a low prevalence area where:

The thalassaemia test shows no
abnormality (i.e. MCH >= 27);
and
 Family origin questionnaire
does not indicate an origin
outside UK or Northern Europe.
A mother screened for SCD,
thalassaemia and other haemoglobin
variants, via a serum test, is not
covered by this value.
01 No abnormality
detected (NAD)
on screening
Example Hb phenotype: AA
This applies to a mother who, as part of
laboratory testing for abnormal
haemoglobins, has had the Hb A2
measured, and nothing abnormal is
detected.
Where a mother, in a low prevalence
area, is tested for thalassaemia and the
test shows no abnormality (as a result
of which HbA2 is not measured), this
value will not be used for such
circumstances. This will be captured
by value ’00 - Not indicated’.
02 Non-significant
carrier
Example Hb phenotypes: AGPhiladelphia
AJMeerut
The majority of haemoglobins other
than those listed under National Code
[05] will fall into this category.
03 Iron deficiency or
possible alpha
thalassaemia
Alpha thalassaemia in low risk groups
may be masked by iron deficiency (or
with MCH>25)
Alpha thalassaemia or iron deficiency
from low risk group, or from a high risk
group if the MCH is >25 (probable α+)
04 Homozygote or
compound
heterozygote neither
of genetic
significance
Page 70 of 163
Example Hb phenotypes: DIran/DIran
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Maternity Services Data Set User Guidance
05 Significant carrier
V2.1
25/03/2013
Example Hb phenotypes: AS, AC,
ADPunjab,
AE, AOArab,
ALepore,
thal trait,
thal trait
There may be more than one genetic
risk, for example a sickle carrier with
MCH<25 from a high risk group for α0
06 Homozygote or
compound
heterozygote
either or both of
genetic
significance
Example Hb phenotypes: CC, Cβ thal,
DD-Punjab, EE
07 Significant
disorder
Example Hb phenotypes: SS, SC, SD,
SE, SOArab, S thal, βthal Maj/Inter
08 Repeat required
Repeat required for any variant or
condition not yet identified, or where an
unsuitable sample has been received
09 Result pending
This value will be captured where:
There may be more than one genetic
risk, for example a patient with Hb Cβthalassaemia.


The test result does not indicate
an existing variant or condition
and therefore needs further
investigation. There are over
1,000 variants and so it may
take anything up to two years to
identify the specific variant, and
consequently align it to the
appropriate disorder type.
A mother is a surrogate or has
used an egg donor. As the
haemoglobinopathy screening
test is for inherited blood
disorders, surrogacy and egg
donors will not yield any useful
haemoglobinopathy information
for the current pregnancy.
This value must not be used where a
data provider is still awaiting the
outcome of the test because pathology
is still processing the sample.
10 Screening
Declined
Page 71 of 163
This national code should not ever be
returned. If the screening offer was
declined by the mother, then this group
would not be sent at all.
Copyright ©2013 Health and Social Care Information Centre
Maternity Services Data Set User Guidance
5.3.12.
V2.1
25/03/2013
MAT301 Maternity Care Plan
MAT301 Maternity Care Plan
Description
The data items in this group relate to antenatal, birth and postpartum care plans, and
captures the initial plan and subsequent changes to each care plan.
For the purpose of this data set, antenatal and postpartum care plans only capture the
type of lead care professional, and changes in type of lead care professional. The birth
plan captures additional information, specifically related to place of birth.
The first antenatal plan should be produced at the booking appointment (NICE CG62)
and reviewed at subsequent antenatal appointments. Any changes thereafter are largely
dependent on the outcome of screening tests and antenatal complications.
The first birth care plan should be produced at 34 weeks gestation (NICE CG62).
Changes to birth plans will be captured to the point of ONSET OF ESTABLISHED
LABOUR DATE TIME. Any changes thereafter will be classed as transfers and
indicated by differences in planned and actual place of delivery.
Group Level Validation and Repeating Rules
These rules are fully described in the appropriate section for this group within the
document Maternity Data Set Technical Output Specification.
Additional Notes on Data Items
Data Item Name
Additional Notes
LOCAL PATIENT
IDENTIFIER
(MOTHER)
This is the unique system identifier that identifies the mother.
This is the primary key that enables groups of data to be joined
together. As such this is a mandated item and the record will be
rejected if it is not included within this group.
Where multiple systems are used it is acceptable to include a
prefix to the Local Patient Identifier, which relates to the system.
The prefix enables each identifier to remains truly unique for all
submissions from an organisation.
Duplicate Local Patient Identifiers within the same submission
file will cause the entire file to be rejected. Duplicate Local
Patient Identifiers across multiple submission files will cause
both records to be rejected even if it is unique within each
submission file.
MATERNITY CARE
PLAN DATE
The date on which a care plan was agreed with the mother. This
covers antenatal, birth and postnatal care plans. If this date is
not within the reporting period, the group will be rejected.
MATERNITY CARE
PLAN TYPE
The stage of maternity to which the care plan applies (antenatal,
birth care, postpartum).
LEAD CARE
PROFESSIONAL
TYPE (MATERNITY)
The professional category of the clinician with overall
responsibility for care during the pregnancy.
Page 72 of 163
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Maternity Services Data Set User Guidance
SITE CODE (OF
INTENDED PLACE
OF DELIVERY)
V2.1
25/03/2013
Home births
In the case of a home birth, this data item will be null.
Site code link and format
If provided, the SITE CODE should exist in national organisation
tables.
NHS Trust site codes consist of five characters, and commence
with the letter R (i.e. Rxxxx).
Where the data providers system does not hold SITE CODE,
locally held values should be mapped to the national code.
DELIVERY PLACE
TYPE CODE
(INTENDED)
The type of intended place of delivery (e.g. NHS Hospital,
domestic address).
DELIVERY PLACE
TYPE (INTENDED
MIDWIFERY UNIT
TYPE)
The type of Midwifery Unit where the delivery is intended to take
place.
DELIVERY PLACE
CHANGE REASON
CODE
The reason for a change in the planned place of birth in the
event that the place of delivery is different from the place
originally intended. This includes both a change in the type of
place or a geographical change.
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5.3.13.
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MAT303 Downs Syndrome Screening Test
MAT303 Downs Syndrome Screening Test
Description
This group captures information on the offer status and the outcome of the Downs
Syndrome Screening test.
The offer for screening is normally made (and responded to) when the mother is given
the ‘Screening tests for you and your baby’ booklet (or its equivalent). Therefore it is
likely that the values in OFFER DATE and BOOKLET GIVEN DATE will be identical.
A mother may delay or change her response. Where data providers record both
responses, then two groups can be submitted, with OFFER DATE reflecting the two
different days the decision was made. Where data providers do not record all the
“intermediate” decisions, then one group may be submitted with the mother’s final
decision recorded in the OFFER STATUS.
The method of test is irrelevant to this data set. The data set does not capture any
information on the Nuchal Translucency (NT) measurement, although the risk ratio may
have been calculated using the NT measurement.
Group Level Validation and Repeating Rules
These rules are fully described in the appropriate section for this group within the
document Maternity Data Set Technical Output Specification.
Additional Notes on Data Items
Data Item Name
Additional Notes
LOCAL PATIENT
IDENTIFIER
(MOTHER)
This is the unique system identifier that identifies the mother.
This is the primary key that enables groups of data to be joined
together. As such this is a mandated item and the record will be
rejected if it is not included within this group.
Where multiple systems are used it is acceptable to include a
prefix to the Local Patient Identifier, which relates to the system.
The prefix enables each identifier to remains truly unique for all
submissions from an organisation.
Duplicate Local Patient Identifiers within the same submission
file will cause the entire file to be rejected. Duplicate Local
Patient Identifiers across multiple submission files will cause
both records to be rejected even if it is unique within each
submission file.
ACTIVITY OFFER
DATE
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Records the date the screening offer was made to the mother.
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Maternity Services Data Set User Guidance
OFFER STATUS
(SCREENING
DOWNS
SYNDROME)
V2.1
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[01] Offered and undecided
[01] Offered and undecided is a transient value, which will, in
most cases, be superseded by [02] Offered and declined or [03]
Offered and accepted.
The only time where [01] Offered and undecided should be
submitted is where a mother considers the screening offer but is
unable to confirm how she wishes to progress before the
submission window closes for the reporting period that contains
the OFFER DATE (i.e. this is the last chance for the data
provider to submit this group before it will be rejected due to
being for the wrong reporting period).
If she subsequently confirms her wishes, then the group should
be resent with the OFFER DATE set to the date the mother
made the decision.
[AC] Alternative choice – diagnostic offered
Where a mother chooses to bypass the screening test, for the
diagnostic test (likely to be due to existing risk factors).
[SP] Not eligible - for stage in pregnancy
Where a mother presents to maternity care services late in
pregnancy and, as a consequence, cannot be screened for
downs syndrome, as determined by the healthcare professional
(Note - current national guidelines recommend screening to be
only be performed up to 20 weeks + 0 days gestation)94.
BLOOD TEST
SAMPLE DATE
(SCREENING
DOWNS
SYNDROME)
Local systems may have been developed in such a manner that
the blood test sample date is only captured once. In this case,
this single date needs to be cascaded to all the groups relating
to the blood test sample.
INVESTIGATION
RISK RATIO
RESULT
(SCREENING
DOWNS
SYNDROME)
This data item captures the risk ratio for each fetus. Since the
risk ratio can vary in length (e.g. 1:200, 1:8000, 1:50000), the
data item does not have a fixed length. Data providers can
submit any value so long as the first part of the ratio has one
digit and the second part of the ratio does not exceed 5 digits
(99999).
MATERNITY
SCREENING TESTS
BOOKLET GIVEN
DATE
The offer for screening is normally made (and responded to)
when the mother is given the ‘Screening tests for you and your
baby’ booklet (or its equivalent). Therefore it is likely that the
values in OFFER DATE and BOOKLET GIVEN DATE will be
identical
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5.3.14.
V2.1
25/03/2013
MAT305 Fetal Anomaly Screening Test
MAT305 Fetal Anomaly Screening Test
Description
This group captures information on the fetal anomaly scan and offer.
National guidelines, as developed by the UK NSC’s Fetal Anomaly Screening
Programme (FASP), recommend that the fetal anomaly scan should be performed
between 18 weeks + 0 days and 20 weeks + 6 days95. Although the validity of the scan
is reduced after 23 weeks and 6 days, for women presenting late in pregnancy, a scan
may be performed at any gestation, if deemed appropriate by a health care professional.
The data item OFFER STATUS (ULTRASOUND FETAL ANOMALY SCREENING) will
only capture 'not eligible - for stage in pregnancy' where a healthcare professional does
not deem the fetal anomaly scan to be a viable option (due to the gestational length).
A mother may delay or change her response. Where data providers record both
responses, then two groups can be submitted, with OFFER DATE reflecting the two
different days the decision was made. Where data providers do not record all the
“intermediate” decisions, then one group may be submitted with the mother’s final
decision recorded in the OFFER STATUS.
Where the dating scan assessments are performed during the fetal anomaly scan, the
data provider capture the same date in data items PROCEDURE DATE (ULTRASOUND
DATING SCAN) and PROCEDURE DATE TIME (ULTRASOUND FETAL ANOMALY
SCREENING). The matching values across the two data items will indicate that a
‘combined’ dating-fetal anomaly scan was undertaken. Where a fetal anomaly is
identified at the ‘combined’ dating-fetal anomaly scan’, confirmed abnormalities will be
captured in this group.
Where scans are repeated for further investigations or to assess each fetus in multi-fetus
pregnancies, the group should be repeated for each PROCEDURE DATE.
Group Level Validation and Repeating Rules
These rules are fully described in the appropriate section for this group within the
document Maternity Data Set Technical Output Specification.
Additional Notes on Data Items
Data Item Name
Additional Notes
18+0 and 20+6 weeks fetal anomaly scan – National standards and guidelines for England 2010 –
[http://fetalanomaly.screening.nhs.uk/standardsandpolicies]
95
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LOCAL PATIENT
IDENTIFIER
(MOTHER)
V2.1
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This is the unique system identifier that identifies the mother.
This is the primary key that enables groups of data to be joined
together. As such this is a mandated item and the record will be
rejected if it is not included within this group.
Where multiple systems are used it is acceptable to include a
prefix to the Local Patient Identifier, which relates to the system.
The prefix enables each identifier to remains truly unique for all
submissions from an organisation.
Duplicate Local Patient Identifiers within the same submission
file will cause the entire file to be rejected. Duplicate Local
Patient Identifiers across multiple submission files will cause
both records to be rejected even if it is unique within each
submission file.
FETAL ORDER
(ULTRASOUND
FETAL ANOMALY
SCREENING)
The purpose of this data item is NOT to create a unique ID for a
fetus for the duration of the pregnancy. This data item will only
capture the order the fetus was assessed in this particular scan.
This data item will NOT be used to link a fetus result:


To the same fetus where scans are repeated
To a baby, after birth.
In a singleton pregnancy, the value must always be 1.
ACTIVITY OFFER
DATE
The date that the fetal anomaly screening test was offered. This
item is not mandated, but if the Activity Offer Date and
Procedure Date are both blank (or the Offer Date is after the
Procedure Date or before the Booking Appointment Date from
MAT101), then the group will be rejected.
OFFER STATUS
(ULTRASOUND
FETAL ANOMALY
SCREENING)
[01] Offered and undecided
[01] Offered and undecided is a transient value, which will, in
most cases, be superseded by [02] Offered and declined or [03]
Offered and accepted.
The only time where [01] Offered and undecided should be
submitted is where a mother considers the screening offer but is
unable to confirm how she wishes to progress before the
submission window closes for the reporting period that contains
the OFFER DATE (i.e. this is the last chance for the data
provider to submit this group before it will be rejected due to
being for the wrong reporting period).
If she subsequently confirms her wishes, then the group should
be resent with the OFFER DATE set to the date the mother
made the decision.
[SP] Not eligible - for stage in pregnancy
Where a mother presents to maternity care services late in
pregnancy and, as a consequence, cannot be screened for fetal
anomalies, as determined by the healthcare professional.
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PROCEDURE DATE
TIME
(ULTRASOUND
FETAL ANOMALY
SCREENING)
In a multi-fetus pregnancy, the PROCEDURE DATE TIME must
be the same for each fetus.
INVESTIGATION
RESULT
(ULTRASOUND
FETAL ANOMALY
SCREENING)
The fetal anomaly scan can identify structural conditions beyond
the eleven considered for this data item.
The detection rates of other anomalies is below 50% and , as a
consequence, UK NSC has recommended that, for reliability
purposes, only the 11 conditions should be specifically
referenced by this data item. Any other observed abnormality is
captured by the value [XX] Other
Where multiple ‘other’ anomalies are identified, a group with a
result of [XX] Other will be repeated for each anomaly.
Trisomy
 Trisomy 18 is also referred to as Edwards Syndrome
 Trisomy 13 is also referred to as Patau Syndrome
Where data providers have a different coding structure for
anomalies, these should be mapped to the national codes.
Observed abnormalities
This data item will capture all identified/observed fetal
anomalies. It is not necessary for the anomaly to be confirmed.
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5.3.15.
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MAT306 Antenatal Appointment
MAT306 Antenatal Appointment
Description
This group only captures information on antenatal appointments attended by the
mother. Where they are missed or cancelled, irrespective of reason, they are out of
scope (i.e. the group should not be submitted).
First contact and Booking Appointment
This group must not be used to submit data relating to the date of first contact or booking
appointment. Separate groups exist for these two appointments.
Location
The location of an antenatal appointment has no bearing on whether this group should
be submitted. The antenatal appointment could take place in the community or at an
acute Trust site.
Group Level Validation and Repeating Rules
These rules are fully described in the appropriate section for this group within the
document Maternity Data Set Technical Output Specification.
Additional Notes on Data Items
Data Item Name
Additional Notes
LOCAL PATIENT
IDENTIFIER
(MOTHER)
This is the unique system identifier that identifies the mother.
This is the primary key that enables groups of data to be joined
together. As such this is a mandated item and the record will be
rejected if it is not included within this group.
Where multiple systems are used it is acceptable to include a
prefix to the Local Patient Identifier, which relates to the system.
The prefix enables each identifier to remains truly unique for all
submissions from an organisation.
Duplicate Local Patient Identifiers within the same submission
file will cause the entire file to be rejected. Duplicate Local
Patient Identifiers across multiple submission files will cause
both records to be rejected even if it is unique within each
submission file.
ACTIVITY DATE
(ANTENATAL
APPOINTMENT)
Page 80 of 163
Date of attendance at Antenatal Appointment (excluding First
Contact and Booking Appointment). If Appointment Date is not
within the reporting period, the group will be rejected.
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Maternity Services Data Set User Guidance
5.3.16.
V2.1
25/03/2013
MAT307 Medical Diagnosis
MAT307 Medical Diagnosis
Description
This group captures information on non-obstetric medical conditions diagnosed during
the pregnancy outside the routine antenatal screening process.
Where conditions are diagnosed through the routine antenatal screening process, these
diagnoses must not be repeated in this group.
Where a mother has multiple conditions relating to the same generic disorder, the
disorder must only be captured once.
Group Level Validation and Repeating Rules
These rules are fully described in the appropriate section for this group within the
document Maternity Data Set Technical Output Specification.
Additional Notes on Data Items
Data Item Name
Additional Notes
LOCAL PATIENT
IDENTIFIER
(MOTHER)
This is the unique system identifier that identifies the mother.
This is the primary key that enables groups of data to be joined
together. As such this is a mandated item and the record will be
rejected if it is not included within this group.
Where multiple systems are used it is acceptable to include a
prefix to the Local Patient Identifier, which relates to the system.
The prefix enables each identifier to remains truly unique for all
submissions from an organisation.
Duplicate Local Patient Identifiers within the same submission
file will cause the entire file to be rejected. Duplicate Local
Patient Identifiers across multiple submission files will cause
both records to be rejected even if it is unique within each
submission file.
DIAGNOSIS DATE
The person property observed date for diagnostic observations
recorded about a mother.
MATERNITY
MEDICAL
DIAGNOSIS TYPE
(CURRENT
PREGNANCY)
Where data providers capture diagnoses at a lower level then
they should be mapped to an appropriate value stated in the
output data item list.
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MAT309 Maternity Obstetric Diagnosis
MAT309 Maternity Obstetric Diagnosis
Description
This group consisting of data item MATERNITY OBSTETRIC DIAGNOSIS TYPE
(CURRENT PREGNANCY) captures information on conditions diagnosed in pregnancy.
Diagnoses definitions are available from table 2.4.
Group Level Validation and Repeating Rules
These rules are fully described in the appropriate section for this group within the
document Maternity Data Set Technical Output Specification.
Additional Notes on Data Items
Data Item Name
Additional Notes
LOCAL PATIENT
IDENTIFIER
(MOTHER)
This is the unique system identifier that identifies the mother.
This is the primary key that enables groups of data to be joined
together. As such this is a mandated item and the record will be
rejected if it is not included within this group.
Where multiple systems are used it is acceptable to include a
prefix to the Local Patient Identifier, which relates to the system.
The prefix enables each identifier to remains truly unique for all
submissions from an organisation.
Duplicate Local Patient Identifiers within the same submission
file will cause the entire file to be rejected. Duplicate Local
Patient Identifiers across multiple submission files will cause
both records to be rejected even if it is unique within each
submission file.
DIAGNOSIS DATE
The person property observed date for diagnostic observations
recorded about a mother.
MATERNITY
OBSTETRIC
DIAGNOSIS TYPE
(CURRENT
PREGNANCY)
Where data providers capture diagnoses at a lower level then
they should be mapped to an appropriate value stated in the
output data item list.
Detailed description of each national code listed below:
[01]
Severe preeclampsia requiring preterm birth
Severe hypertension (a diastolic
blood pressure ≥ 110mmHg on two
occasions or systolic blood pressure
≥ 170mmHg on two occasions) and
significant proteinuria (at least 1
g/litre)96.
96
England. RCOG (Mar 2006) Green-top 10(A): The Management of severe pre-eclampsia/eclampsia. 1st ed. pp. 1
[http://www.rcog.org.uk/files/rcog-corp/uploaded-files/GT10aManagementPreeclampsia2006.pdf]
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[02]
Haemolytic
anaemia, elevated liver
enzymes and Low
platelet count (HELLP)
A combined liver and blood clotting
disorder which is a complication of
pre-eclampsia97.
[03]
‘Eclampsia’ is defined as the
occurrence of one or more
convulsions superimposed on preeclampsia98.
Eclampsia
‘Pre-eclampsia’ is defined as
pregnancy-induced hypertension in
association with proteinuria (>
300mg in 24 hours) ± oedema and
virtually any organ system may be
affected99.
[05]
Liver cholestasis
of pregnancy
Also referred to as ‘obstetric
cholestasis’.
A multifactorial condition of
pregnancy characterised by intense
pruritus (severe itching) in the
absence of a skin rash, with
abnormal liver function tests (LFTs),
neither of which have an alternative
cause and both of which remit
following delivery100.
[06]
Gestational
diabetes mellitus
Carbohydrate intolerance resulting in
hyperglycaemia of variable severity
with onset or first recognition during
pregnancy and with a return to
normal after birth101.
RCOG, Medical terms explained, HELLP syndrome – [http://www.rcog.org.uk/womens-health/patient-information/medicalterms-explained]
97
98
England. RCOG (Mar 2006) Green-top 10(A): The Management of severe pre-eclampsia/eclampsia. 1st ed. pp. 1
[http://www.rcog.org.uk/files/rcog-corp/uploaded-files/GT10aManagementPreeclampsia2006.pdf]
99
England. RCOG (Mar 2006) Green-top 10(A): The Management of severe pre-eclampsia/eclampsia. 1st ed. pp. 1
[http://www.rcog.org.uk/files/rcog-corp/uploaded-files/GT10aManagementPreeclampsia2006.pdf]
100
England. RCOG (Jan 2006) Green-top 43: Obstetric cholestasis. 1st ed. pp. 1 [http://www.rcog.org.uk/files/rcogcorp/uploaded-files/GT43ObstetricCholestasis2006.pdf]
101
England. NICE (Corrected Jun 2008) CG62 Antenatal Care: Full Guideline, London: RCOG Press, pp. 205
[http://www.nice.org.uk/nicemedia/live/11947/40145/40145.pdf]
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‘Gestational hypertension’ is defined
as a new hypertension presenting
after 20 weeks without significant
proteinuria102.
[07]
Gestational
hypertension
‘Hypertension’ is defined as a single
diastolic blood pressure of 110
mmHg or any consecutive readings
of 90 mmHg on more than one
occasion at least 4 hours apart103.
[08]
Gestational
proteinuria
Greater than 300mg excretion of
protein in a 24 hour collected urine,
two clean catch urine specimens at
least 4 hours apart with 2+
proteinuria by dipstick104.
[09]
Antepartum
haemorrhage
Bleeding from the genital tract after
the 24th week of pregnancy until the
birth of the baby.105
11]
Feto-maternal
haemorrhage (FMH)
Fetal blood entering the maternal
circulation106.
[18]
Symphysis pubis
dysfunction
A collection of signs and symptoms
of discomfort and pain in the pelvic
area, including pelvic pain radiating
to the upper thighs and perineum.107
[19]
The placenta being inserted wholly
or in part into the lower segment of
the uterus.108
Placenta praevia
England. NICE (Feb 2010) Hypertension in pregnancy, The management of hypertensive disorders during pregnancy –
Full Guideline, pp. 4 [http://www.nice.org.uk/guidance/index.jsp?action=download&o=47351]
102
103
England. NICE (Corrected Jun 2008) CG62 Antenatal Care: Full Guideline, London: RCOG Press, pp. 218
[http://www.nice.org.uk/nicemedia/live/11947/40145/40145.pdf]
104
England. NICE (Corrected Jun 2008) CG62 Antenatal Care: Full Guideline, London: RCOG Press, pp. 218
[http://www.nice.org.uk/nicemedia/live/11947/40145/40145.pdf]
105
Oxford concise colour medical dictionary, new 3rd edition, Oxford University Press, 2002
106
England. NICE (Aug 2008), TA41 Pregnancy- routine anti-D prophylaxis for rhesus negative women, pp. 4
[http://www.nice.org.uk/nicemedia/live/12047/41690/41690.pdf]
107
England. NICE (Corrected Jun 2008) CG62 Antenatal Care: Full Guideline, London: RCOG Press, pp. 113
[http://www.nice.org.uk/nicemedia/live/11947/40145/40145.pdf]
108
England. RCOG (Jan 2011) Guideline No. 27: Placenta Praevia, Placenta Praevia Accreta and Vasa Praevia: Diagnosis
and management. 2nd ed, pp. 1 [http://www.rcog.org.uk/files/rcog-corp/uploaded-files/GT27PlacentaPreviaAccreta2005.pdf]
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[20]
Severe preeclampsia
5.3.18.
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Severe hypertension (a diastolic
blood pressure ≥ 110 mmHg on two
occasions or systolic blood pressure
≥ 170 mmHg on two occasions) and
significant proteinuria (at least 1
g/litre)109.
MAT310 Antenatal Admission
MAT310 Antenatal Admission
Description
This group captures information for a mother who has been admitted to a hospital as an
in-patient, prior to onset of labour. This will include admissions for non-obstetric
conditions, planned caesarean, inductions and false labours.
If a mother commences labour before being discharged from hospital, which should
always be the case for inductions and caesarean sections, the data item DISCHARGE
DATE (HOSPITAL PROVIDER SPELL ANTENATAL) will be null. In such scenarios, the
combination of data items DISCHARGE DATE (HOSPITAL PROVIDER SPELL
ANTENATAL) and DISCHARGE DATE (MOTHER MATERNITY SERVICES) will yield
sufficient information to indicate the mother delivered whilst being admitted in the
antenatal period of the pregnancy.
Group Level Validation and Repeating Rules
These rules are fully described in the appropriate section for this group within the
document Maternity Data Set Technical Output Specification.
Additional Notes on Data Items
Data Item Name
Additional Notes
LOCAL PATIENT
IDENTIFIER
(MOTHER)
This is the unique system identifier that identifies the mother.
This is the primary key that enables groups of data to be joined
together. As such this is a mandated item and the record will be
rejected if it is not included within this group.
Where multiple systems are used it is acceptable to include a
prefix to the Local Patient Identifier, which relates to the system.
The prefix enables each identifier to remains truly unique for all
submissions from an organisation.
Duplicate Local Patient Identifiers within the same submission
file will cause the entire file to be rejected. Duplicate Local
Patient Identifiers across multiple submission files will cause
both records to be rejected even if it is unique within each
submission file.
109
England. RCOG (Mar 2006) Green-top 10(A): The Management of severe pre-eclampsia/eclampsia. 1st ed. pp. 1
[http://www.rcog.org.uk/files/rcog-corp/uploaded-files/GT10aManagementPreeclampsia2006.pdf]
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START DATE
(HOSPITAL
PROVIDER SPELL
ANTENATAL)
V2.1
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Date of antenatal inpatient admission. If the Discharge Date is
blank (or is after the end of the reporting period) and Start Date
is not within the reporting period, the entire group will be
rejected.
If Discharge Date is populated and Start Date is more than 9
months prior to the Discharge Date, the entire group will be
rejected.
DISCHARGE DATE
(HOSPITAL
PROVIDER SPELL
ANTENATAL)
Date of antenatal inpatient discharge. If the Discharge Date is
populated:
If it is before the start of the reporting period, the entire group
will be rejected.
If it is after the end of the reporting period a warning will be
output.
If it is before the Start Date, the entire group will be rejected.
5.3.19.
MAT401 Medical Induction Method
MAT401 Medical Induction Method
Description
This group captures all the methods used (if any) to induce labour.
Group Level Validation and Repeating Rules
These rules are fully described in the appropriate section for this group within the
document Maternity Data Set Technical Output Specification.
Additional Notes on Data Items
Data Item Name
Additional Notes
LOCAL PATIENT
IDENTIFIER
(MOTHER)
This is the unique system identifier that identifies the mother.
This is the primary key that enables groups of data to be joined
together. As such this is a mandated item and the record will be
rejected if it is not included within this group.
Where multiple systems are used it is acceptable to include a
prefix to the Local Patient Identifier, which relates to the system.
The prefix enables each identifier to remains truly unique for all
submissions from an organisation.
Duplicate Local Patient Identifiers within the same submission
file will cause the entire file to be rejected. Duplicate Local
Patient Identifiers across multiple submission files will cause
both records to be rejected even if it is unique within each
submission file.
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ONSET OF
ESTABLISHED
LABOUR DATE
TIME
Date/time when established labour is confirmed - regular painful
contractions and progressive cervical dilation.
MEDICAL
INDUCTION OF
LABOUR METHOD
Where data providers capture methods at a lower level then
they should be mapped to an appropriate value stated in the
output data item list.
OXYTOCIN
ADMINISTERED
DATE TIME
This captures the date and time oxytocin was administered for
either induction or augmentation.
5.3.20.
Where oxytocin is administered for any other purpose, such as
delivery of the placenta, this is outside the scope of this data
item.
MAT404 Labour and Delivery
MAT404 Labour and Delivery
Description
This group captures information on the routine labour & delivery episode and is required
for all pregnancies where labour occurs.
Where some data items in the group become redundant, due to other interventions (e.g.
caesarean section) or the exact times are unknown (e.g. due to a mother delivering
without support from a healthcare professional), they may be submitted as null. An
example of this would be the Onset of Established Labour Date Time.
The definitions for the 3 stages of labour are available from NICE CG55 – Intrapartum
Care (Chapter 7)110.
Group Level Validation and Repeating Rules
The rules are fully described in the appropriate section for this group within the
document Maternity Data Set Technical Output Specification.
Additional Notes on Data Items
Data Item Name
Additional Notes
ONSET OF
ESTABLISHED
LABOUR DATE
TIME
Date/time when established labour is confirmed - regular painful
contractions and progressive cervical dilation.
This is not a mandatory item as a mother may not necessarily
go into labour. For example the pregnancy may result in a
planned caesarean section. The data item Procedure Date Time
(Caesarean Section) would be used in this case.
110
England. NICE (Corrected Jun 2008) CG55 Intrapartum Care: Full Guideline, London, London: RCOG Press, pp. 139,
156, 174 [http://www.nice.org.uk/nicemedia/live/11837/36275/36275.pdf]
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PROCEDURE DATE
TIME (CAESAREAN
SECTION)
The date/time of the caesarean section (i.e. time of Knife to
skin). If Onset Date Time and Caesarean Date Time are both
populated, then if Caesarean Date Time is before the Onset
Date Time, the group will be rejected.
LOCAL PATIENT
IDENTIFIER
(MOTHER)
This is the unique system identifier that identifies the mother.
This is the primary key that enables groups of data to be joined
together. As such this is a mandated item and the record will be
rejected if it is not included within this group.
Where multiple systems are used it is acceptable to include a
prefix to the Local Patient Identifier, which relates to the system.
The prefix enables each identifier to remains truly unique for all
submissions from an organisation.
Duplicate Local Patient Identifiers within the same submission
file will cause the entire file to be rejected. Duplicate Local
Patient Identifiers across multiple submission files will cause
both records to be rejected even if it is unique within each
submission file.
PRESENTATION AT
ONSET OF LABOUR
The presentation of the (first) fetus at onset of labour.
START DATE TIME
(MOTHER
DELIVERY
HOSPITAL
PROVIDER SPELL)
Date of in-patient admission, to a hospital, as part of the onset
of labour, or for a caesarean section procedure.
DATE TIME OF
DECISION TO
DELIVER
This data item is only relevant where the delivery is accelerated
by caesarean section or instrumental birth (usually due to
prolonged labour or complications during labour). NB. For
elective caesarean sections, the commencement of labour is not
deemed as a method of accelerating labour, and so this data
item is out of scope for such scenarios.
Multi-fetus pregnancy
In a multi-fetus pregnancy this data item should refer to the final
delivery. However, this group does not capture the specific
fetus for whom this data item refers.
Alignment with data item DELIVERY METHOD (CURRENT
BABY) in group MAT503 Birth Details
Where DATE TIME OF DECISION TO DELIVER is used, an
appropriate value must be captured in data item DELIVERY
METHOD (CURRENT BABY).
RUPTURE OF
MEMBRANES DATE
TIME
Page 88 of 163
In the event of a multi-fetus pregnancy with multiple amniotic
sacs (synonym with amnions), the data item will capture the
date and time the first membrane is ruptured.
Copyright ©2013 Health and Social Care Information Centre
Maternity Services Data Set User Guidance
RUPTURE OF
MEMBRANES
METHOD
V2.1
25/03/2013
Where data providers capture methods at a lower level then
they should be mapped to an appropriate value stated in the
output data item list.
Where membranes are ruptured at caesarean section, the value
[NA] Not applicable is to be used.
The value [NA] Not applicable may be used in two
circumstances. The membranes may have ruptured long before
the onset of labour (e.g. weeks). The membranes may not
rupture at all before the birth of the baby, which will then be
delivered within the amniotic sac.
NB. Artificial rupture of membranes is synonymous with
amniotomy.
ARTIFICIAL
RUPTURE OF
MEMBRANES
REASON
Where data providers capture reasons at a lower level then they
should be mapped to an appropriate value stated in the output
data item list.
Some examples of mapping:


ONSET OF SECOND
STAGE OF LABOUR
DATE TIME
Contractions inco-ordinate maps to [02] Augmentation of
labour
Apply Fetal Scalp Electrode, Bradycardia, Persistent
early decelerations and Fetal tachycardia map to [03]
Improve fetal assessment.
NICE CG55 states: Women should be informed that, while the
length of established first stage of labour varies between
women, first labours last on average 8 hours and are unlikely to
last over 18 hours. Second and subsequent labours last on
average 5 hours and are unlikely to last over 12 hours.
As a check for dates/times sent in error, the central system will
output a warning if the time between ONSET OF SECOND
STAGE and ONSET OF ESTABLISHED LABOUR is greater
than 48 hours. This time period accommodates data providers
who may only being submitting this data at “date” level.
END OF THIRD
STAGE OF LABOUR
DATE TIME
For multi-fetus pregnancies, this date and time will be captured
at the point the last placenta is delivered.
EPISIOTOMY
PERFORMED
REASON
Where data providers capture critical incident events in a
different way or at a lower level then they should be mapped to
an appropriate value stated in the national code list.
DELIVERY OF
PLACENTA
METHOD
Where data providers capture methods at a lower level then
they should be mapped to an appropriate value stated in the
output data item list.
As a check for dates/times sent in error, the central system will
output a warning if the time between END OF THIRD STAGE
OF LABOUR and ONSET OF SECOND STAGE is greater than
24 hours. This time period accommodates data providers who
may only being submitting this data at “date” level.
Where the placenta is removed at caesarean section, this will
map to [03] Manual Removal.
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V2.1
25/03/2013
DISCHARGE DATE
TIME (MOTHER
POST DELIVERY
HOSPITAL
PROVIDER SPELL)
The date and time when the mother was discharged home,
following delivery, to the community midwifery service. If
Discharge Date Time is populated and is before the start date of
the reporting period, the group will be rejected.
ORGANISATION
CODE (POSTNATAL
PATHWAY LEAD
PROVIDER)
NHS organisation site code of post natal lead provider
organisation. List of all NHS organisation sites (with their
codes) are available from the Connecting for Health (CfH)
website (via the N3 network). If Organisation Code is not in
national organisation tables a warning will be reported.
5.3.21.
If Onset Date Time and Discharge Date Time are both
populated, then if Discharge Date Time is before the Onset Date
Time, the group will be rejected.
MAT405 Pain Relief in Labour and Delivery
MAT405 Pain Relief in Labour and Delivery
Description
This group captures information on the administration/non-administration or supply/nonsupply of pain relief to the mother, during the birth episode.
The group must be repeated each time pain relief (non-anaesthetic) is administered
during labour & delivery. Where the same pain relief type is administered for more than
one stage of labour & delivery, a group should be submitted for each occurrence.
Group Level Validation and Repeating Rules
The rules are fully described in the appropriate section for this group within the
document Maternity Data Set Technical Output Specification.
Additional Notes on Data Items
Data Item Name
Additional Notes
LOCAL PATIENT
IDENTIFIER
(MOTHER)
This is the unique system identifier that identifies the mother.
This is the primary key that enables groups of data to be joined
together. As such this is a mandated item and the record will be
rejected if it is not included within this group.
Where multiple systems are used it is acceptable to include a
prefix to the Local Patient Identifier, which relates to the system.
The prefix enables each identifier to remains truly unique for all
submissions from an organisation.
Duplicate Local Patient Identifiers within the same submission
file will cause the entire file to be rejected. Duplicate Local
Patient Identifiers across multiple submission files will cause
both records to be rejected even if it is unique within each
submission file.
Page 90 of 163
Copyright ©2013 Health and Social Care Information Centre
Maternity Services Data Set User Guidance
ONSET OF
ESTABLISHED
LABOUR DATE
TIME
V2.1
25/03/2013
Date/time when established labour is confirmed - regular painful
contractions and progressive cervical dilation.
If onset of established labour date time and procedure date time
(Caesarean section) are both blank or not within the reporting
period, then the group will be rejected.
If onset of established labour date time is populated and is after
date of birth (from MAT502), then the group will be rejected.
If onset of established labour date time and procedure date time
(Caesarean section) are both populated, and onset of
established labour date time is after procedure date time
(Caesarean section), then the group will be rejected.
PROCEDURE DATE
TIME (CAESAREAN
SECTION)
The date/time of the caesarean section (i.e. time of Knife to
skin). If procedure date time (Caesarean section), is populated
and is not with the reporting period or after the date of birth
(from MAT502), then the group will be rejected.
PAIN RELIEF TYPE
IN LABOUR AND
DELIVERY
The circumstances under which the data item may be used are:



Labour
Instrumental delivery
Removal of placenta
Where data providers capture pain relief types at a lower level
then they should be mapped to an appropriate value stated in
the output data item list. NB. Where a mother is given cocodamol, this should map to [04] Paracetamol.
Where a mother uses multiple types of pain relief, the group
must be repeated for each type.
Page 91 of 163
Copyright ©2013 Health and Social Care Information Centre
Maternity Services Data Set User Guidance
5.3.22.
V2.1
25/03/2013
MAT406 Anaesthesia Type in Labour and Delivery
MAT406 Anaesthesia Type in Labour and Delivery
Description
This group captures information on the administration of anaesthesia to the mother
during labour & delivery.
Examples of stages during labour & delivery where the group may be generated are:




Labour
Instrumental delivery
Caesarean section
Removal of placenta
The group must be repeated each time anaesthesia is administered during labour &
delivery. Where the same anaesthesia type is administered for more than one stage of
labour & delivery, a group should be submitted for each occurrence.
Group Level Validation and Repeating Rules
The rules are fully described in the appropriate section for this group within the
document Maternity Data Set Technical Output Specification.
Additional Notes on Data Items
Data Item Name
Additional Notes
LOCAL PATIENT
IDENTIFIER
(MOTHER)
This is the unique system identifier that identifies the mother.
This is the primary key that enables groups of data to be joined
together. As such this is a mandated item and the record will be
rejected if it is not included within this group.
Where multiple systems are used it is acceptable to include a
prefix to the Local Patient Identifier, which relates to the system.
The prefix enables each identifier to remains truly unique for all
submissions from an organisation.
Duplicate Local Patient Identifiers within the same submission
file will cause the entire file to be rejected. Duplicate Local
Patient Identifiers across multiple submission files will cause
both records to be rejected even if it is unique within each
submission file.
Page 92 of 163
Copyright ©2013 Health and Social Care Information Centre
Maternity Services Data Set User Guidance
ONSET OF
ESTABLISHED
LABOUR DATE
TIME
V2.1
25/03/2013
Date/time when established labour is confirmed - regular painful
contractions and progressive cervical dilation. If onset of
established labour date time and procedure date time
(Caesarean section) are both blank, then the group will be
rejected.
If onset of established labour date time and procedure date time
(Caesarean section) is not within the reporting period, then the
group will be rejected.
If onset of established labour date time is populated and is after
date of birth (from MAT502), then the group will be rejected.
If onset of established labour date time and procedure date time
(Caesarean section) are both populated, and onset of
established labour date time is after procedure date time
(Caesarean section), then the group will be rejected.
PROCEDURE DATE
TIME (CAESAREAN
SECTION)
The date/time of the caesarean section (i.e. time of Knife to
skin). If Procedure Date Time (Caesarean Section) is populated
and is not with the reporting period, then the group will be
rejected.
If Procedure Date Time (Caesarean Section) is populated and is
after Date Of Birth (from MAT502), then the group will be
rejected.
ANAESTHESIA
TYPE IN LABOUR
AND DELIVERY
Page 93 of 163
Where data providers capture anaesthesia types at a lower level
then they should be mapped to an appropriate value stated in
the output data item list.
Copyright ©2013 Health and Social Care Information Centre
Maternity Services Data Set User Guidance
5.3.23.
V2.1
25/03/2013
MAT408 Maternal Critical Incident
MAT408 Maternal Critical Incident
Description
This group captures information on critical incidents in the maternity care pathway.
The term Critical Incident is synonymous with Patient Safety Incident. The term Patient
Safety Incident has been adopted by both RCOG and the National Patient Safety
Agency (NPSA)).
The NPSA has defined a patient safety incident as “any unintended or unexpected
incident that could have or did lead to harm for one or more patients receiving NHSfunded healthcare.”
Group Level Validation and Repeating Rules
The rules are fully described in the appropriate section for this group within the
document Maternity Data Set Technical Output Specification.
Additional Notes on Data Items
Data Item Name
Additional Notes
LOCAL PATIENT
IDENTIFIER
(MOTHER)
This is the unique system identifier that identifies the mother.
This is the primary key that enables groups of data to be joined
together. As such this is a mandated item and the record will be
rejected if it is not included within this group.
Where multiple systems are used it is acceptable to include a
prefix to the Local Patient Identifier, which relates to the system.
The prefix enables each identifier to remains truly unique for all
submissions from an organisation.
Duplicate Local Patient Identifiers within the same submission
file will cause the entire file to be rejected. Duplicate Local
Patient Identifiers across multiple submission files will cause
both records to be rejected even if it is unique within each
submission file.
MATERNAL
CRITICAL INCIDENT
DATE TIME
Page 94 of 163
Date/time of event considered as a critical incident. If Critical
Incident Date Time is not within the reporting period, the group
will be rejected.
Copyright ©2013 Health and Social Care Information Centre
Maternity Services Data Set User Guidance
MATERNAL
CRITICAL INCIDENT
TYPE
V2.1
25/03/2013
The national code list for this data item is based on RCOG’s
suggested trigger list for incident reporting in maternity as
published in their Clinical governance advice No 2 - Improving
patient safety: Risk management for maternity and
Gynaecology111.
The RCOF suggested trigger list is a mixture of diagnoses,
observations, procedures and outcomes. This data item only
captures a subset of the list as some triggers are already
captured by other data items in the data set. The table below
shows the full trigger list and the corresponding data items
within the data set.
Where data providers capture critical incident events in a
different way or at a lower level then they should be mapped to
an appropriate value stated in the output data item list.
Additional explanation of some of the national code values are
below:
01 Undiagnosed breech
02 PPH >=500ml and
<=999ml
03 PPH >= 1000ml and
<=1499ml
04 PPH >= 1500ml
Although RCOG’s green top guideline
No. 52 – Prevention and
management of postpartum
haemorrhage112 defines slightly
different PPH thresholds, the data set
values have been agreed by RCOG,
NPSA and CQC. RCOG guidelines
are to be updated as per the data set
thresholds.
For reference purposes, RCOG
defines:


minor PPH as >=500ml and
<=1000ml
major PPH as > 1000ml
05 Return to theatre
06 Hysterectomy /
laparotomy
07 Anaesthetic
complications
Some examples of anaesthetic
complications are:



Failed intubation
Anaphylactic reaction to
anaesthetic
Drug administration error
08 Intensive care
admission
111
England. RCOG (Sep 2009) Clinical governance advice No 2 - Improving patient safety: Risk management for maternity
and Gynaecology. 3rd ed. pp. 5 [http://www.rcog.org.uk/files/rcog-corp/CGA2ImprovingPatientSafety2009.pdf]
112
England. RCOG (May 2009) Green Top Guideline No 52: Prevention and management of postpartum haemorrhage. 1st
ed. pp. 1 [http://www.rcog.org.uk/files/rcog-corp/Green-top52PostpartumHaemorrhage.pdf]
Page 95 of 163
Copyright ©2013 Health and Social Care Information Centre
Maternity Services Data Set User Guidance
09 Venous
thromboembolism
10 Pulmonary
embolism
V2.1
25/03/2013
Venous thromboembolism is defined
as:
The blocking of a blood vessel by a
blood clot formed at or dislodged from
its site of origin.
It includes both Deep Vein
Thrombosis (DVT) and Pulmonary
Embolism (PE).
Deep vein thrombosis (DVT) is
defined as:
Venous thrombosis that occurs in the
“deep veins” in the legs, thighs, or
pelvis.113
Pulmonary embolism (PE) is defined
as:
A blood clot that breaks off from the
deep veins and travels round the
circulation to block the pulmonary
arteries (arteries in the lung).114
11 Unsuccessful
forceps or ventouse
12 Amniotic Fluid
Embolism
Amniotic fluid embolism is a rare
complication of pregnancy, where
amniotic fluid, fetal cells, hair or other
debris enters the mother's blood
stream via the placental bed of the
uterus and triggers an allergic
reaction. This is distinct from a blood
embolism.
Mapping between RCOG Clinical Governance Advice No. 2’s ‘Suggested trigger list
for incident reporting in maternity’ and MSDS data items
Maternal critical incident
MSDS data item
Maternal death
MAT604 Maternal Death
PERSON DEATH DATE TIME (MOTHER)
England. NICE (2010) CG92 Venous thromboembolism – reducing the risk: Full guideline, London: National Clinical
Guideline Centre at the Royal College of Physicians, pp. 26 [http://www.nice.org.uk/nicemedia/live/12695/47920/47920.pdf]
113
England. NICE (2010) CG92 Venous thromboembolism – reducing the risk: Full guideline, London: National Clinical
Guideline Centre at the Royal College of Physicians, pp. 31 [http://www.nice.org.uk/nicemedia/live/12695/47920/47920.pdf]
114
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Maternity Services Data Set User Guidance
Undiagnosed breech
V2.1
25/03/2013
MAT408 Maternal Critical Incident
MATERNAL CRITICAL INCIDENT
[01] Undiagnosed breech
Shoulder dystocia
MAT504 Baby Complications at Birth
BABY COMPLICATION AT BIRTH
[01] Shoulder dystocia
PPH >= 500ml and <=999ml
MAT408 Maternal Critical Incident
MATERNAL CRITICAL INCIDENT
[02] PPH >=500ml and <=999ml
PPH >= 1000ml and <=1499ml
MAT408 Maternal Critical Incident
MATERNAL CRITICAL INCIDENT
[03] PPH >= 1000ml and <=1499ml
PPH >=1500ml
MAT408 Maternal Critical Incident
MATERNAL CRITICAL INCIDENT
[04] PPH >= 1500ml
Return to theatre
MAT408 Maternal Critical Incident
MATERNAL CRITICAL INCIDENT
[05] Return to theatre
Eclampsia
MAT309 Maternity Obstetric Diagnosis
MATERNITY OBSTETRIC DIAGNOSIS TYPE
(CURRENT PREGNANCY)
[03] Eclampsia
Hysterectomy / laparotomy
MAT408 Maternal Critical Incident
MATERNAL CRITICAL INCIDENT
[06] Hysterectomy / laparotomy
Anaesthetic complications
MAT408 Maternal Critical Incident
MATERNAL CRITICAL INCIDENT
[07] Anaesthetic complications
Intensive care admission
MAT408 Maternal Critical Incident
MATERNAL CRITICAL INCIDENT
[08] Intensive care admission
Page 97 of 163
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Maternity Services Data Set User Guidance
Venous thromboembolism
V2.1
25/03/2013
MAT408 Maternal Critical Incident
MATERNAL CRITICAL INCIDENT
[09] Venous thromboembolism
MAT408 Maternal Critical Incident
Pulmonary embolism
MATERNAL CRITICAL INCIDENT
[10] Pulmonary embolism
MAT409 Genital Tract Trauma
3rd / 4th degree tears
TRAUMATIC LESION OF GENITAL TRACT
[06] Perineal tear - third degree
[07] Perineal tear - fourth degree
MAT408 Maternal Critical Incident
Unsuccessful forceps or
ventouse
MATERNAL CRITICAL INCIDENT
[11] Unsuccessful forceps or ventouse
MAT409 Genital Tract Trauma
Uterine rupture
TRAUMATIC LESION OF GENITAL TRACT
MAT603 Postpartum Readmission
Readmission of mother
START DATE (HOSPITAL PROVIDER SPELL
POSTPARTUM)
5.3.24.
MAT409 Genital Tract Trauma
MAT409 Genital Tract Trauma
Description
This group captures the type of tear, of the genital tract, suffered by the mother during
the labour & delivery episode.
Group Level Validation and Repeating Rules
The rules are fully described in the appropriate section for this group within the
document Maternity Data Set Technical Output Specification.
Additional Notes on Data Items
Data Item Name
Page 98 of 163
Additional Notes
Copyright ©2013 Health and Social Care Information Centre
Maternity Services Data Set User Guidance
LOCAL PATIENT
IDENTIFIER
(MOTHER)
V2.1
25/03/2013
This is the unique system identifier that identifies the mother.
This is the primary key that enables groups of data to be joined
together. As such this is a mandated item and the record will be
rejected if it is not included within this group.
Where multiple systems are used it is acceptable to include a
prefix to the Local Patient Identifier, which relates to the system.
The prefix enables each identifier to remains truly unique for all
submissions from an organisation.
Duplicate Local Patient Identifiers within the same submission
file will cause the entire file to be rejected. Duplicate Local
Patient Identifiers across multiple submission files will cause
both records to be rejected even if it is unique within each
submission file.
ONSET OF
ESTABLISHED
LABOUR DATE
TIME
Page 99 of 163
Date/time when established labour is confirmed - regular painful
contractions and progressive cervical dilation.
Copyright ©2013 Health and Social Care Information Centre
Maternity Services Data Set User Guidance
TRAUMATIC
LESION OF
GENITAL TRACT
V2.1
25/03/2013
Tear and episiotomy
Where a mother suffers a tear and also undergoes an
episiotomy to extend the tear, the data provider must submit two
groups, one indicating the type of tear and one indicating an
episiotomy.
[01] None
[02] Labial tear
[03] Vaginal wall tear
[04] Perineal tear - first degree
Definition: Injury to perineal skin only115.
[05] Perineal tear - second degree
Definition: Injury to perineum involving perineal muscles but not
involving the anal sphincter116.
[06] Perineal tear - third degree
Definition: A partial or complete disruption of the anal sphincter
muscles, which may involve either or both the external (EAS)
and internal anal sphincter (IAS) muscles117.
[07] Perineal tear - fourth degree
Definition: A disruption of the anal sphincter muscles with a
breach of the rectal mucosa118.
[08] Episiotomy
[09] Cervical tear
[10] Urethral tear
[11] Clitoral tear
[12] Anterior incision
Anterior incision is captured where it is undertaken in the
intrapartum period for defibulation. Anterior incision for
defibulation undertaken in the antenatal period is outside the
scope of this data item.
5.3.25.
MAT501 Fetus Outcome
MAT501 Fetus Outcome
115
England. RCOG (Mar 2007) Green-top Guideline No. 29: The management of third and fourth degree tears. 2nd ed. pp. 3
[http://www.rcog.org.uk/files/rcog-corp/uploaded-files/GT29ManagementThirdFourthDegreeTears2007.pdf]
116
England. RCOG (Mar 2007) Green-top Guideline No. 29: The management of third and fourth degree tears. 2nd ed. pp. 3
[http://www.rcog.org.uk/files/rcog-corp/uploaded-files/GT29ManagementThirdFourthDegreeTears2007.pdf]
117
England. RCOG (Mar 2007) Green-top Guideline No. 29: The management of third and fourth degree tears. 2nd ed. pp. 1
[http://www.rcog.org.uk/files/rcog-corp/uploaded-files/GT29ManagementThirdFourthDegreeTears2007.pdf]
118
England. RCOG (Mar 2007) Green-top Guideline No. 29: The management of third and fourth degree tears. 2nd ed. pp. 1
[http://www.rcog.org.uk/files/rcog-corp/uploaded-files/GT29ManagementThirdFourthDegreeTears2007.pdf]
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V2.1
25/03/2013
Description
This group is required for each fetus identified at the dating scan, irrespective of the
outcome.
Group Level Validation and Repeating Rules
The rules are fully described in the appropriate section for this group within the
document Maternity Data Set Technical Output Specification.
Additional Notes on Data Items
Data Item Name
Additional Notes
LOCAL PATIENT
IDENTIFIER
(MOTHER)
This is the unique system identifier that identifies the mother.
This is the primary key that enables groups of data to be joined
together. As such this is a mandated item and the record will be
rejected if it is not included within this group.
Where multiple systems are used it is acceptable to include a
prefix to the Local Patient Identifier, which relates to the system.
The prefix enables each identifier to remains truly unique for all
submissions from an organisation.
Duplicate Local Patient Identifiers within the same submission
file will cause the entire file to be rejected. Duplicate Local
Patient Identifiers across multiple submission files will cause
both records to be rejected even if it is unique within each
submission file.
FETAL ORDER
(FETUS OUTCOME)
The purpose of this data item is NOT to create a unique ID for a
fetus. This data item will only capture the order the fetus was
reported in this particular group.
This data item will NOT be used to link a fetus outcome:


To particular scan results.
To a particular baby.
In a singleton pregnancy, the value must always be 1.
DATE OF
PREGNANCY
OUTCOME
(CURRENT FETUS)
Page 101 of 163
Date of outcome of each fetus. If DATE OF PREGNANCY
OUTCOME (CURRENT FETUS) is not within the reporting
period, the group will be rejected.
Copyright ©2013 Health and Social Care Information Centre
Maternity Services Data Set User Guidance
PREGNANCY
OUTCOME
(CURRENT FETUS)
V2.1
25/03/2013
Where data providers capture pregnancy outcomes in a different
way or at a lower level then they should be mapped to an
appropriate value stated in the national code list.
[XX] Other inc vanishing/papyraceous twin, ectopic
Examples of when value ‘other’ will be used are:



Ectopic pregnancy
Trophoblastic disease
Vanishing / papyraceous twin
[30] Miscarriage
Miscarriages may be diagnosed by a GP or a Gynaecology unit,
so data providers are encouraged to set up relevant processes
to capture miscarriage data from all relevant sources.
[40] Termination of Pregnancy < 24weeks
[50] Termination of Pregnancy >= 24weeks
The data set does not distinguish whether the termination was
by medical (e.g. Mifepristone, Misoprostol etc) or surgical
means.
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5.3.26.
V2.1
25/03/2013
MAT502 Baby's Demographics and Birth Details
MAT502 Baby's Demographics and Birth Details
Description
This group captures data collected when the baby is born.
The group must be submitted for all registrable births including both live births and
stillbirths.
A MAT502 group must be transmitted within the reporting period that includes the date of
birth. It should also be retransmitted in subsequent reporting periods should the data
provider wish to amend values or when flowing any other group containing the baby's
NHS number.
Group Level Validation and Repeating Rules
The rules are fully described in the appropriate section for this group within the
document Maternity Data Set Technical Output Specification.
Additional Notes on Data Items
Data Item Name
Additional Notes
LOCAL PATIENT
IDENTIFIER (BABY)
The data item will be captured for all live births and stillbirths.
The data set development process has highlighted that the
Local Patient Identifier (LPI) is captured for all registrable births.
This is the unique system identifier that identifies the baby. This
is the primary key that enables groups of data to be joined
together. As such this is a mandated item and the record will be
rejected if it is not included within this group.
Where multiple systems are used it is acceptable to include a
prefix to the Local Patient Identifier, which relates to the system.
The prefix enables each identifier to remains truly unique for all
submissions from an organisation.
Duplicate Local Patient Identifiers within the same submission
file will cause the entire file to be rejected. Duplicate Local
Patient Identifiers across multiple submission files will cause
both records to be rejected even if it is unique within each
submission file.
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Maternity Services Data Set User Guidance
LOCAL PATIENT
IDENTIFIER
(MOTHER)
V2.1
25/03/2013
This is the unique system identifier that identifies the mother.
This is the primary key that enables groups of data to be joined
together. As such this is a mandated item and the record will be
rejected if it is not included within this group.
Where multiple systems are used it is acceptable to include a
prefix to the Local Patient Identifier, which relates to the system.
The prefix enables each identifier to remains truly unique for all
submissions from an organisation.
Duplicate Local Patient Identifiers within the same submission
file will cause the entire file to be rejected. Duplicate Local
Patient Identifiers across multiple submission files will cause
both records to be rejected even if it is unique within each
submission file.
ORGANISATION
CODE (LOCAL
PATIENT
IDENTIFIER (BABY))
This will identify the organisation where the Local Patient
Identifier (Baby) was issued. It is necessary where
organisations have gone through a merger or split into a new or
existing organisation.
If Local Patient Identifiers are not modified during the merger or
split of an organisation, then the issuing Organisation Code of
the Local Patient Identifier (even if now discontinued) should be
sent in this field. However if the Local Patient Identifier has been
modified since the organisation change i.e. by prefix etc, then
the new organisation code should be used.
DATE TIME OF
BIRTH (BABY)
Date and time of birth of baby.
If Date Of Birth is after end of the reporting period, then the
group will be rejected.
If Date Of Birth more than one year prior to the start of the
reporting period, then the group will be rejected.
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Maternity Services Data Set User Guidance
NHS NUMBER
(BABY)
V2.1
25/03/2013
The data item should be captured for all live births and stillbirths.
Most maternity systems are linked to NN4B so the NHS number
should be readily available from maternity systems.
The importance of the NHS Number
When the NHS number is provided this will be used instead of
the Local Patient Identifier as the primary unique identifier for a
mother or baby.
The capture of the NHS number is vital as this is the only
identifier that allows the mother and baby to be tracked across
different organisations or across a single organisation when
multiple Local Patient Identifiers have been used for a mother or
baby.
Although this is not a mandated field, as not all mothers and
babies have NHS numbers, data quality reports will be produced
to identify the completeness of this field and it is recommended
that local care providers use this as one of the primary data
quality metrics for all patient level data sets.
No NHS number
In cases where a baby’s NHS number is unavailable data
providers must submit a null NHS number and [07] Number not
present and trace not required in NHS NUMBER STATUS
INDICATOR CODE (BABY).
NHS NUMBER
STATUS
INDICATOR CODE
(BABY)
Whether the NHS number of the baby has been verified.
PERSON
PHENOTYPIC SEX
The Person Phenotypic Sex of the baby. This is as observed by
a person (such as a Care Professional) and is not self-stated.
PERSON DEATH
DATE TIME (BABY)
This item captures information on babies dying before 28
completed days of birth (i.e. within 27 days and 23 hours + 59
minutes). i.e. the data set captures information on early and late
neonatal deaths.
A group must be submitted for any known death not only
where a death certificate is issued.
Data providers also report neonatal deaths to MBRRACE-UK
(Mothers and Babies - Reducing Risk through Audits and
Confidential Enquiries across the UK) as part of the national
Maternal, Newborn and Infant Clinical Outcomes Review
Programme.
Data submission to MBRRACE-UK must continue and data
providers must ensure that data submitted to the MCDS central
data warehouse and MBRRACE-UK is consistent.
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Maternity Services Data Set User Guidance
BIRTH ORDER
(MATERNITY
SERVICES
SECONDARY USES)
V2.1
25/03/2013
Singleton and multi-fetus pregnancies
The data item captures the sequence in which the baby was
born, with [01] indicating the first or only birth in the sequence
(i.e. singleton), [02] indicating the second birth in the sequence,
[03] indicating the third, and so on.
Unknown birth order
The data provider should submit [UU] Unknown.
BIRTH WEIGHT
Weight of baby in grams at birth.
GESTATION
LENGTH (AT BIRTH)
Data providers may be able to derive this value by comparing
the DATE TIME OF BIRTH (BABY) with the mother’s
ESTIMATED DATE OF DELIVERY (AGREED).
DELIVERY METHOD
(CURRENT BABY)
Where data providers capture delivery methods in a different
way or at a lower level then they should be mapped to an
appropriate value stated in the national code list.
Further explanation of the national code list is below:
0 Spontaneous Vertex
Normal vaginal delivery,
occipitoanterior
1 Spontaneous Other
Cephalic
Cephalic vaginal delivery with
abnormal presentation of head at
delivery, without instruments, with or
without manipulation
2 Low forceps, not
breech
E.g. forceps, low application, without
manipulation. Includes forceps
delivery not otherwise specified.
Where an NHS Trust only captures
‘forceps’, the method of delivery will
map to ‘Low forceps, not breech’.
Page 106 of 163
3 Other Forceps, not
breech
E.g. forceps with manipulation.
Includes high forceps and mid
forceps)
4 Ventouse, Vacuum
extraction
N/A
5 Breech
Spontaneous delivery assisted or
unspecified. Includes partial breech
extraction)
6 Breech Extraction
Not otherwise specified. Includes total
breech extraction and version with
breech extraction
Copyright ©2013 Health and Social Care Information Centre
Maternity Services Data Set User Guidance
7 Elective caesarean
section
V2.1
25/03/2013
Caesarean section before, or at onset
of, labour.
Where a mother, scheduled for a
caesarean section (i.e. elective
caesarean section), is admitted to an
NHS Trust due to early onset of labour
(and without maternal or fetal
compromise) and subsequently has a
caesarean section, she will still be
classed as having an ‘elective
caesarean section’.
8 Emergency
caesarean section
Where a caesarean section is planned
but is performed urgently, due a
complication, the method of delivery
will be classed as ‘emergency
caesarean section’.
9 Other
E.g. application of weight to leg in
breech delivery. Includes destructive
operation to facilitate delivery and
other surgical or instrumental delivery.
DELIVERED IN
WATER INDICATOR
The data item refers to babies delivered in a birthing pool. This
is irrespective of whether the baby’s head is above or under the
water at the point of delivery.
APGAR SCORE (5
MINUTES)
NICE CG55 recommends that the Apgar score be routinely
captured for all babies at 1 and 5 minutes119. For purpose of the
data set, the Apgar score is only required at 5 minutes (where
undertaken).
APGAR SCORE (5 MINUTES) is not relevant for stillbirths
SITE CODE (OF
ACTUAL PLACE OF
DELIVERY)
In the case of a home birth, this data item will be null.
Codes provided will be validated against the NHS Organisation
Data Service (ODS).
Where data providers capture site of delivery in a different
format or at a lower level than the ODS codes, then they should
be mapped to an appropriate value stated in the national code
list.
DELIVERY PLACE
TYPE CODE
(ACTUAL)
Type of unit in which baby was delivered.
DELIVERY PLACE
TYPE (ACTUAL
MIDWIFERY UNIT
TYPE)
This data item will only be relevant where the data item
DELIVERY PLACE TYPE (ACTUAL) = [0] In NHS hospital –
delivery facilities associated with midwife ward
119 England. NICE (Corrected Jun 2008) CG55 Intrapartum Care: Full Guideline, London: RCOG Press, pp. 187
[http://www.nice.org.uk/nicemedia/live/11837/36275/36275.pdf]
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Maternity Services Data Set User Guidance
BABY FIRST FEED
DATE TIME
V2.1
25/03/2013
Date/time on which baby had first feed. If FIRST FEED DATE
TIME is populated and is before the DATE OF BIRTH, then the
group will be rejected.
This data item is not relevant for stillbirths (this will not be
checked by the central system).
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Maternity Services Data Set User Guidance
BABY FIRST FEED
BREAST MILK
STATUS
V2.1
25/03/2013
NICE CG37 has defined a clinical care pathway for the care of
the mother and the baby, after birth120. The pathway defines
core standards for the different stages of the postnatal period.
For the immediate postnatal period (i.e. within 24 hours of
delivery), the following two standards are relevant for this group:


During the first hour of life, skin to skin contact should be
encouraged
During the first hour of life, breastfeeding should be
initiated
This group provides full conformance towards the skin to skin
contact standard, but not so to the breastfeeding standard. The
feeding data items in this group only capture data on the first
feed whereas the Standard wishes to identify breastfeeding
status within the first hour.
The MSDS in combination with the Children’s and Young
People’s Health Services (CYPHS) Secondary Uses Data Set
captures breast milk feeding information at 2 further stages:


Neonatal discharge from hospital (captured in MSDS)
6-8 weeks (captured in CYPHS Secondary Uses Data
Set)
Where data providers capture the status in a different way or at
a lower level then they should be mapped to an appropriate
value stated in the national code list.
Further explanation of the national code list is below:
National Code
Definition
01 Maternal Breast Milk
For the purpose of this data
set, ‘maternal breast milk’ will
refer to any type of human
breast milk, from the initial
‘Colostrum’ through to the
richer established breast milk.
02 Donor Breast Milk
Where a baby is given breast
milk from a wet nurse, the
data provider will capture
‘donor breast milk’
03 Not Breast Milk
Where a baby is given a form
of feed other than breast milk,
the data provider will capture
‘Not breast milk’.
The data set does not have
the capacity to record whether
the baby initially declined
breast milk.
England. NICE (2006) CG37 Postnatal Care – Full guideline, London: National Collaborating Centre for Primary Care
and Royal College of General Practitioners, pp. 25 [http://www.NICE.org.uk/NICEmedia/pdf/CG037fullguideline.pdf]
120
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Maternity Services Data Set User Guidance
BABY BREAST
MILK STATUS (AT
DISCHARGE FROM
HOSPITAL)
V2.1
25/03/2013
The item captures whether the baby was receiving breast milk at
the point of discharge from a NHS unit (e.g. hospital, midwifery
led unit, NNU etc).
For home deliveries, the data item must be captured at the
closest postnatal visit to 48 hours of birth.
Where a baby receives donor breast milk or breast milk from a
wet nurse, the data provider must capture [01] Exclusively
Breast Milk Feeding.
Where data providers capture the information in a different
format or at a lower level, then they should be mapped to an
appropriate value stated in the national code list.
NB. Breastfeeding status at 6-8 weeks is captured in the
Children’s and Young People’s Health Service (CYPHS)
Secondary Uses Data Set.
SKIN TO SKIN
CONTACT WITHIN
ONE HOUR
Page 110 of 163
Whether or not baby had skin to skin contact with mother in the
first hour of life. This data item is not relevant for stillbirths (this
will not be checked by the central system).
Copyright ©2013 Health and Social Care Information Centre
Maternity Services Data Set User Guidance
5.3.27.
V2.1
25/03/2013
MAT504 Baby Complications at Birth
MAT504 Baby Complications at Birth
Description
This group captures complications encountered or observed during the labour & delivery
episode.
Group Level Validation and Repeating Rules
The rules are fully described in the appropriate section for this group within the
document Maternity Data Set Technical Output Specification.
Additional Notes on Data Items
Data Item Name
Additional Notes
LOCAL PATIENT
IDENTIFIER (BABY)
The data item will be captured for all live births and stillbirths.
The data set development process has highlighted that the
Local Patient Identifier (LPI) is captured for all registrable births.
This is the unique system identifier that identifies the baby. This
is the primary key that enables groups of data to be joined
together. As such this is a mandated item and the record will be
rejected if it is not included within this group.
Where multiple systems are used it is acceptable to include a
prefix to the Local Patient Identifier, which relates to the system.
The prefix enables each identifier to remains truly unique for all
submissions from an organisation.
Duplicate Local Patient Identifiers within the same submission
file will cause the entire file to be rejected. Duplicate Local
Patient Identifiers across multiple submission files will cause
both records to be rejected even if it is unique within each
submission file.
BABY
COMPLICATION AT
BIRTH
Where data providers capture complications in a different way or
at a lower level then they should be mapped to an appropriate
value stated in the national code list.
Further explanation of the national code list is below:
[01]
Shoulder
dystocia
A complication of delivery that requires
additional obstetric manoeuvres to
release the shoulders after gentle
downward traction has failed121.
121
Adapted from England. RCOG (Dec 2005) Guideline No. 42:Shoulder Dystocia. 1st ed. pp. 1
[http://www.rcog.org.uk/files/rcog-corp/uploaded-files/GT42ShoulderDystocia2005.pdf]
Page 111 of 163
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Maternity Services Data Set User Guidance
[02]
Cord prolapse
V2.1
25/03/2013
The descent of the umbilical cord
through the cervix alongside (occult) or
past the presenting part (overt) in the
presence of ruptured membranes.122
[03]
Acute fetal
compromise
Immediate threat to life of fetus
[04] Fetal acidaemia
Cord arterial pH <7.05123
[05] Meconium
Aspiration Syndrome
The aspiration of meconium into the
lungs during intrauterine gasping, or
when the baby takes its first breath,
leading to respiratory distress requiring
oxygen and/or other respiratory
support.
This code should not be used for
Stillbirths
[06] Acute blood loss
Hypovolaemic shock requiring
emergency volume replacement at
birth.
122
England. RCOG (Apr 2008) Green-top Guideline No. 50: Umbilical cord prolapse. 1st ed. pp. 1
[http://www.rcog.org.uk/files/rcog-corp/uploaded-files/GT50UmbilicalCordProlapse2008.pdf]
123
De La Fuente and S. Soothill, P. 2001. Prediction of asphyxia with fetal gas analysis. In Levene MI, Chervenak FA,
Whittle M (Eds.) Fetal and neonatal neurology and neurosurgery (Chapter 26), 3rd edition, London: Churchill Livingstone
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Maternity Services Data Set User Guidance
5.3.28.
V2.1
25/03/2013
MAT506 Neonatal Resuscitation Method
MAT506 Neonatal Resuscitation Method
Description
This group captures any methods used to resuscitate the baby, immediately after birth.
Any resuscitation after the labour & delivery episode is outside the scope of the data set.
Group Level Validation and Repeating Rules
The rules are fully described in the appropriate section for this group within the
document Maternity Data Set Technical Output Specification.
Additional Notes on Data Items
Data Item Name
Additional Notes
LOCAL PATIENT
IDENTIFIER (BABY)
The data item will be captured for all live births and stillbirths.
The data set development process has highlighted that the
Local Patient Identifier (LPI) is captured for all registrable births.
This is the unique system identifier that identifies the baby. This
is the primary key that enables groups of data to be joined
together. As such this is a mandated item and the record will be
rejected if it is not included within this group.
Where multiple systems are used it is acceptable to include a
prefix to the Local Patient Identifier, which relates to the system.
The prefix enables each identifier to remains truly unique for all
submissions from an organisation.
Duplicate Local Patient Identifiers within the same submission
file will cause the entire file to be rejected. Duplicate Local
Patient Identifiers across multiple submission files will cause
both records to be rejected even if it is unique within each
submission file.
NEONATAL
RESUSCITATION
METHOD
Page 113 of 163
Where data providers capture methods in a different way or at a
lower level then they should be mapped to an appropriate value
stated in the national code list.
Copyright ©2013 Health and Social Care Information Centre
Maternity Services Data Set User Guidance
5.3.29.
V2.1
25/03/2013
MAT507 Neonatal Resuscitation Drug or Fluid
MAT507 Neonatal Resuscitation Drug or Fluid
Description
This group captures the drugs and fluids administered for resuscitating the baby
immediately after birth.
Any resuscitation after the labour & delivery episode is outside the scope of the data set.
The group is relevant for each registrable birth (i.e. stillbirth and live birth).
Group Level Validation and Repeating Rules
The rules are fully described in the appropriate section for this group within the
document Maternity Data Set Technical Output Specification.
Additional Notes on Data Items
Data Item Name
Additional Notes
LOCAL PATIENT
IDENTIFIER (BABY)
The data item will be captured for all live births and stillbirths.
The data set development process has highlighted that the
Local Patient Identifier (LPI) is captured for all registrable births.
This is the unique system identifier that identifies the baby. This
is the primary key that enables groups of data to be joined
together. As such this is a mandated item and the record will be
rejected if it is not included within this group.
Where multiple systems are used it is acceptable to include a
prefix to the Local Patient Identifier, which relates to the system.
The prefix enables each identifier to remains truly unique for all
submissions from an organisation.
Duplicate Local Patient Identifiers within the same submission
file will cause the entire file to be rejected. Duplicate Local
Patient Identifiers across multiple submission files will cause
both records to be rejected even if it is unique within each
submission file.
NEONATAL
RESUSCITATION
DRUG OR FLUID
Page 114 of 163
Where data providers capture drugs and fluids in a different way
or at a lower level then they should be mapped to an
appropriate value stated in the national code list.
Copyright ©2013 Health and Social Care Information Centre
Maternity Services Data Set User Guidance
5.3.30.
V2.1
25/03/2013
MAT508 Neonatal Critical Care Admission
MAT508 Neonatal Critical Care Admission
Description
This group captures information on each admission to a Neonatal Unit (NNU).
A ‘Neonatal Unit’ is defined as:
A unit which provides additional care for babies over and above the essential core
postnatal care that all babies should receive.
There are different levels of complexity of additional care, defined by British Association
of Perinatal Medicine (BAPM) categories, which can be offered by an individual neonatal
unit.



Special Care Units (SCU): Provide special care for their own local population.
Also provide, by agreement with their neonatal network, some high dependency
services.
Local Neonatal Units (LNU): Provide special care and high dependency care
and a restricted volume of intensive care (as agreed locally). Would expect to
transfer babies who require complex or longer-term intensive care to a Neonatal
Intensive Care Unit.
Neonatal Intensive Care Unit (NICU): Larger intensive care units that provide
the whole range of medical (and sometimes surgical) neonatal care for their local
population and additional care for babies and their families referred from the
neonatal network in which they are based, and also from other networks when
necessary to deal with peaks of demand or requests for specialist care not
available elsewhere. Many will be sited within perinatal centres that are able to
offer similarly complex obstetric care. These units will also require close working
arrangements with all of the relevant paediatric sub-specialties.
The majority of NNUs capture admission and hospital stay details on electronic neonatal
systems. It is therefore likely that the data items in this group will be available from
these systems.
Group Level Validation and Repeating Rules
The rules are fully described in the appropriate section for this group within the
document Maternity Data Set Technical Output Specification.
Additional Notes on Data Items
Data Item Name
Page 115 of 163
Additional Notes
Copyright ©2013 Health and Social Care Information Centre
Maternity Services Data Set User Guidance
LOCAL PATIENT
IDENTIFIER (BABY)
V2.1
25/03/2013
The data item will be captured for all live births and stillbirths.
The data set development process has highlighted that the
Local Patient Identifier (LPI) is captured for all registrable births.
This is the unique system identifier that identifies the baby. This
is the primary key that enables groups of data to be joined
together. As such this is a mandated item and the record will be
rejected if it is not included within this group.
Where multiple systems are used it is acceptable to include a
prefix to the Local Patient Identifier, which relates to the system.
The prefix enables each identifier to remains truly unique for all
submissions from an organisation.
Duplicate Local Patient Identifiers within the same submission
file will cause the entire file to be rejected. Duplicate Local
Patient Identifiers across multiple submission files will cause
both records to be rejected even if it is unique within each
submission file.
TRANSFER START
DATE TIME
(NEONATAL UNIT)
Date/time on which baby was admitted to Neonatal Unit (NNU).
If TRANSFER START DATE is not within the reporting period,
the group will be rejected.
This data item is not relevant for stillbirths (this will not be
checked by the central system).
SITE CODE (OF
ADMITTING
NEONATAL UNIT)
Page 116 of 163
Codes provided will be validated against the NHS Organisation
Data Service (ODS).
Where data providers capture site information in a different
format or at a lower level than the ODS codes, then they should
be mapped to an appropriate value stated in the national code
list.
Copyright ©2013 Health and Social Care Information Centre
Maternity Services Data Set User Guidance
5.3.31.
V2.1
25/03/2013
MAT510 Neonatal Diagnosis
MAT510 Neonatal Diagnosis
Description
This group captures information on diagnoses prior to discharge from maternity services
or neonatal services. Upon transfer to child health services, any diagnoses will be
outside the remit of the data set.
A neonate may be diagnosed with any number of conditions, but this data set is only
interested in those specified in the national code list within the Maternity Services Data
Set Technical Output Specification.
This data item must only be applied to live births.
Group Level Validation and Repeating Rules
The rules are fully described in the appropriate section for this group within the
document Maternity Data Set Technical Output Specification.
Additional Notes on Data Items
Data Item Name
Additional Notes
LOCAL PATIENT
IDENTIFIER (BABY)
The data item will be captured for all live births and stillbirths.
The data set development process has highlighted that the
Local Patient Identifier (LPI) is captured for all registrable births.
This is the unique system identifier that identifies the baby. This
is the primary key that enables groups of data to be joined
together. As such this is a mandated item and the record will be
rejected if it is not included within this group.
Where multiple systems are used it is acceptable to include a
prefix to the Local Patient Identifier, which relates to the system.
The prefix enables each identifier to remains truly unique for all
submissions from an organisation.
Duplicate Local Patient Identifiers within the same submission
file will cause the entire file to be rejected. Duplicate Local
Patient Identifiers across multiple submission files will cause
both records to be rejected even if it is unique within each
submission file.
DIAGNOSIS DATE
The person property observed date for diagnostic observations
recorded about a mother.
NEONATAL
DIAGNOSIS
Where data providers capture the information in a different
format or at a lower level, then they should be mapped to an
appropriate value stated in the national code list.
Further explanation of the national code list is below:
Page 117 of 163
Copyright ©2013 Health and Social Care Information Centre
Maternity Services Data Set User Guidance
V2.1
[01] Jaundice requiring
phototherapy
25/03/2013
Jaundice (icterus) is defined as:
A yellow coloured tinge to the skin,
and a yellowing of the whites of the
eyes. The body fluids of someone
who is affected by jaundice can also
become yellow in colour.124
Phototherapy is defined as:
Controlling the levels of bilirubin by
placing the baby under a lamp
emitting light in the blue spectrum.
Light energy of the appropriate
wavelength converts the bilirubin in
the skin to a harmless form that can
be excreted in the urine.125
[02] Erb's Palsy
Injury to the nerve roots of the
brachial plexus leading to various
degrees of weakness of the affected
arm.126
[03] Neonatal abstinence
syndrome
Symptoms suffered by infants
withdrawing from substances to
which they have become physically
dependent during intrauterine
exposure requiring regular
observations and/or treatment.
England. NICE (May 2010) CG98 Neonatal Jaundice – Full Guideline, London: RCOG, pp. 33
[http://www.nice.org.uk/nicemedia/live/12986/48678/48678.pdf]
124
England. NICE (May 2010) CG98 Neonatal Jaundice – Full Guideline, London: RCOG, pp. 34
[http://www.nice.org.uk/nicemedia/live/12986/48678/48678.pdf]
125
126
Adapted from England. NICE (Reissued Jul 2008), CG63 Diabetes in Pregnancy: Full Guideline, London, RCOG Press,
pp. xv [http://www.nice.org.uk/nicemedia/live/11946/41320/41320.pdf]
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Copyright ©2013 Health and Social Care Information Centre
Maternity Services Data Set User Guidance
5.3.32.
V2.1
25/03/2013
MAT511 Neonatal Critical Incident
MAT511 Neonatal Critical Incident
Description
This group captures information on neonatal critical incidents in the maternity care
pathway.
The term critical incident is synonymous with patient safety incident. Patient safety
incident has been adopted by both RCOG and the National Patient Safety Agency
(NPSA). The NPSA has defined a patient safety incident as:
Any unintended or unexpected incident that could have or did lead to harm for one or
more patients receiving NHS-funded healthcare127.
Group Level Validation and Repeating Rules
The rules are fully described in the appropriate section for this group within the
document Maternity Data Set Technical Output Specification.
Additional Notes on Data Items
Data Item Name
Additional Notes
LOCAL PATIENT
IDENTIFIER (BABY)
The data item will be captured for all live births and stillbirths.
The data set development process has highlighted that the
Local Patient Identifier (LPI) is captured for all registrable births.
This is the unique system identifier that identifies the baby. This
is the primary key that enables groups of data to be joined
together. As such this is a mandated item and the record will be
rejected if it is not included within this group.
Where multiple systems are used it is acceptable to include a
prefix to the Local Patient Identifier, which relates to the system.
The prefix enables each identifier to remains truly unique for all
submissions from an organisation.
Duplicate Local Patient Identifiers within the same submission
file will cause the entire file to be rejected. Duplicate Local
Patient Identifiers across multiple submission files will cause
both records to be rejected even if it is unique within each
submission file.
NEONATAL
CRITICAL INCIDENT
DATE
The DATE recorded for a NEONATAL CRITICAL INCIDENT
TYPE. If NEONATAL CRITICAL INCIDENT DATE is not within
the reporting period, the group will be rejected.
Patient safety incident definition – Via document ‘National framework for reporting and learning from serious incidents
requiring investigation’ (Mar 2010)
127
[http://www.nrls.npsa.nhs.uk/report-a-patient-safety-incident/patient-safety-direct/serious-incident-reporting-and-learningframework-sirl/]
Page 119 of 163
Copyright ©2013 Health and Social Care Information Centre
Maternity Services Data Set User Guidance
NEONATAL
CRITICAL INCIDENT
TYPE
V2.1
25/03/2013
Alignment with RCOG and NPSA
This data item is based on RCOG’s ‘Suggested trigger list for
incident reporting in maternity’, as published in their document
Clinical governance advice No 2 - Improving patient safety: Risk
management for maternity and Gynaecology128.
The same trigger (related to neonates) list has been re-used for
this data item.
Data mapping
Based on RCOG’s Clinical governance advice No 2, the value
list for this data item is a mixture of diagnoses, observations,
procedures and outcomes. Clinical governance advice No 2
provides a fetal / neonatal trigger list larger than the one listed in
this data item. This data item only captures a subset of the list
as some triggers are already captured by other data items within
the data set. The table below shows the full trigger list and their
corresponding data items within the data set.
[01]
Birth trauma to
the newborn
Any bruising, haematoma,
laceration, fracture or other injury to
the baby, as sustained during birth.
[02]
Fetal laceration at
caesarean section
[03]
Cord pH < 7.1
venous
[04]
Neonatal
seizures
A change in behaviour that is
caused by sudden, abnormal, and
excessive electrical activity in the
brain to a neonate’.129
This code should not be used for
Stillbirths
128
England. RCOG (Sep 2009) Clinical governance advice No 2 - Improving patient safety: Risk management for maternity
and Gynaecology. 3rd ed. pp. 5 [http://www.rcog.org.uk/files/rcog-corp/CGA2ImprovingPatientSafety2009.pdf]
Neonatal seizure – [http://healthlibrary.epnet.com/GetContent.aspx?token=1d460a90-ed32-4663-892bccb4aae1e348&chunkiid=202856]
129
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Maternity Services Data Set User Guidance
V2.1
[05]
Undiagnosed fetal
abnormality
25/03/2013
An undiagnosed fetal abnormality,
normally detected by ultrasound
scan, which may include one or
more of the following:











Anencephaly
Open spina bifida
Serious cardiac heart
abnormalities
Bilateral renal agenesis
Lethal skeletal dysplasia
Trisomy 18
Trisomy 13
Diaphragmatic hernia
Exomphalos
Gastroschisis
Cleft lip
Note – this definition is very specific
to MSDS.
[06]
European
Congenital Anomalies or
Twins (Eurocat)
In England and Wales, NHS Trusts
report congenital anomalies, for live
and stillbirths, to the National
Congenital Anomaly System (run
by ONS). The Congenital Anomaly
System aligns to EUROCAT
(European Concerted Action for
Congenital Anomalies and Twins),
which is a European network of
population-based registries for the
epidemiologic surveillance of
congenital anomalies.
This value is to be used where an
abnormality, specified in the
EUROCAT data form
Further information on the
EUROCAT congenital anomaly
register is available at
http://www.eurocat-network.eu
Page 121 of 163
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V2.1
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Mapping between RCOG Clinical Governance Advice No. 2’s ‘Suggested trigger
list for incident reporting in maternity’ and MSDS data items
Maternal critical incident
MSDS data item(s)
Stillbirth > 500g
OUTCOME OF PREGNANCY (BABY)
BIRTH WEIGHT
Neonatal death
DATE TIME OF DEATH (BABY)
Apgar score <7 at 5 minutes
APGAR SCORE (5 MINUTES)
Birth trauma of the newborn
NEONATAL CRITICAL INCIDENT
Fetal laceration at caesarean
section
NEONATAL CRITICAL INCIDENT
Cord pH <7.05 arterial or <7.1
venous
COMPLICATION AT BIRTH – fetal acidaemia
(only for Cord pH > <7.05 arterial)
NEONATAL CRITICAL INCIDENT (only for Cord
pH <7.1 venous)
Neonatal seizures
NEONATAL CRITICAL INCIDENT
Term baby admitted to neonatal
unit
GESTATIONAL LENGTH (AT BIRTH)
Undiagnosed fetal anomaly
NEONATAL CRITICAL INCIDENT
European congenital abnormalities
and twins (Eurocat)
NEONATAL CRITICAL INCIDENT
Page 122 of 163
ADMISSION DATE TIME (NNU)
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Maternity Services Data Set User Guidance
5.3.33.
V2.1
25/03/2013
MAT513 Newborn Physical Screening Examination
MAT513 Newborn Physical Screening Examination
Description
The group captures the mother’s response to the offer of newborn physical screening
and the newborn physical screening, as performed within 72 hours of birth130.
The offer should be captured for all registrable births (i.e. stillbirths and live births). Data
items relating to date of screening and screening result will only be captured for live
births.
A mother may delay or change her offer response. Where data providers record both
responses, then two groups can be submitted, with OFFER DATE TIME reflecting the
two different days/times the decision was made/recorded. Where data providers do not
record all the “intermediate” decisions, then one group may be submitted with the
mother’s final decision recorded in the OFFER STATUS.
The screening examination looks at many areas but MSDS only records hips, heart,
eyes and, in boys, testes.
Group Level Validation and Repeating Rules
The rules are fully described in the appropriate section for this group within the
document Maternity Data Set Technical Output Specification.
Additional Notes on Data Items
Data Item Name
Additional Notes
LOCAL PATIENT
IDENTIFIER (BABY)
The data item will be captured for all live births and stillbirths.
The data set development process has highlighted that the
Local Patient Identifier (LPI) is captured for all registrable births.
This is the unique system identifier that identifies the baby. This
is the primary key that enables groups of data to be joined
together. As such this is a mandated item and the record will be
rejected if it is not included within this group.
Where multiple systems are used it is acceptable to include a
prefix to the Local Patient Identifier, which relates to the system.
The prefix enables each identifier to remains truly unique for all
submissions from an organisation.
Duplicate Local Patient Identifiers within the same submission
file will cause the entire file to be rejected. Duplicate Local
Patient Identifiers across multiple submission files will cause
both records to be rejected even if it is unique within each
submission file.
Newborn and infant physical examination – Standards and competencies (March 2008)
[http://newbornphysical.screening.nhs.uk/publications]
130
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V2.1
25/03/2013
ACTIVITY OFFER
DATE
The date that the newborn physical screening examination was
offered. This item is not mandated, but if the Activity Offer Date
is outside the reporting period (or the Offer Date is before the
Date of Birth), then the group will be rejected.
OFFER STATUS
(SCREENING
NEWBORN
PHYSICAL
EXAMINATION)
Where data providers capture the information in a different
format or at a lower level, then they should be mapped to an
appropriate value stated in the national code list.
[IE] Ineligible - where it is not possible to examine the baby so
an offer cannot be made. This may be due to:




Stillbirth
Neonatal death in hospital before routine discharge
Moved out of area before newborn examination offer
was possible
Moribund to the extent that offer of newborn examination
was inappropriate
[NR] No response to offer – where the mother was offered the
test (for the baby), but a response was not provided. This may
be due to:


Communication issues (e.g. the test is offered by post,
but a response is not received).
Learning difficulty issues (e.g. the mother is unable to
comprehend that a test is being offered).
SCREENING DATE
(NEWBORN
PHYSICAL
EXAMINATION)
Date of newborn physical examination. If Screening Date is
populated and is not with the reporting period, then the group
will be rejected.
NEWBORN
PHYSICAL
EXAMINATION
RESULTS (HIPS)
Where data providers capture the information in a different
format or at a lower level, then they should be mapped to an
appropriate value stated in the national code list.
NEWBORN
PHYSICAL
EXAMINATION
RESULT (HEART)
Alignment to ‘My personal child health record’
NEWBORN
PHYSICAL
EXAMINATION
RESULT (EYES)
Page 124 of 163
If Screening Date is populated and is before Date Of Birth (from
MAT502), then the group will be rejected.
These four data items are also captured in the ‘My personal
child health record’, albeit in additional granularity.
The expert reference group ruled that the SPOTRN coding
scheme was not appropriate as it combines findings (problems,
observations) with actions (treatment, refer). In addition, the
values are not mutually exclusive; an examination outcome
could be classed as both Problem and Refer. As a
Copyright ©2013 Health and Social Care Information Centre
Maternity Services Data Set User Guidance
NEWBORN
PHYSICAL
EXAMINATION
RESULT (TESTES)
V2.1
25/03/2013
consequence, the MSDS, in conjunction with the CYPHS
Secondary Uses Data Set is adopting a simplified value list:
For data providers who currently record results using SPOTRN
coding, the following mapping must be followed:
SPOTRN Value
MSDS national code list
Satisfactory
[01] Satisfactory
Problem
[02] Problem Identified
Observation
[03] Problem Suspected
Treatment
[02] Problem Identified
Refer
[03] Problem Suspected
Not Examined
[NN] Not Examined
Testes examination for girls
For girls, data providers must submit [NN] Not Examined.
Page 125 of 163
Copyright ©2013 Health and Social Care Information Centre
Maternity Services Data Set User Guidance
5.3.34.
V2.1
25/03/2013
MAT515 Newborn Hearing Screening Test
MAT515 Newborn Hearing Screening Test
Description
The group captures the mother’s response to the offer and result of the newborn hearing
screening.
The offer should be captured for all registrable births (i.e. stillbirths and live births). The
result should only be provided for live births.
A mother may delay or change her response to the offer. Where data providers record
both responses, then two groups can be submitted, with OFFER DATE TIME reflecting
the two different days/times the decision was made/recorded. Where data providers do
not record all the “intermediate” decisions, then one group may be submitted with the
mother’s final decision recorded in the OFFER STATUS.
Where more than one test is undertaken, say due to machine malfunction, and data
providers record both results, then two groups can be submitted, with PROCEDURE
DATE reflecting the two different days the procedure was undertaken. Where data
providers do not record all the “intermediate” results (or where the two procedures were
undertaken on the same day), then one group may be submitted with the final result
recorded in the OUTCOME.
Group Level Validation and Repeating Rules
The rules are fully described in the appropriate section for this group within the
document Maternity Data Set Technical Output Specification.
Additional Notes on Data Items
Data Item Name
Additional Notes
LOCAL PATIENT
IDENTIFIER (BABY)
The data item will be captured for all live births and stillbirths.
The data set development process has highlighted that the
Local Patient Identifier (LPI) is captured for all registrable births.
This is the unique system identifier that identifies the baby. This
is the primary key that enables groups of data to be joined
together. As such this is a mandated item and the record will be
rejected if it is not included within this group.
Where multiple systems are used it is acceptable to include a
prefix to the Local Patient Identifier, which relates to the system.
The prefix enables each identifier to remains truly unique for all
submissions from an organisation.
Duplicate Local Patient Identifiers within the same submission
file will cause the entire file to be rejected. Duplicate Local
Patient Identifiers across multiple submission files will cause
both records to be rejected even if it is unique within each
submission file.
Page 126 of 163
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V2.1
25/03/2013
ACTIVITY OFFER
DATE
The date that the hearing screening test was offered. This item
is not mandated, but if the Activity Offer Date and Procedure
Date are both blank (or the Offer Date is after the Procedure
Date or before the Date of Birth), then the group will be rejected.
OFFER STATUS
(NEWBORN
HEARING
SCREENING)
Whether or not the newborn hearing screening was offered and
accepted. For stillbirths, only the value [IE] Ineligible should be
returned (this will not be checked by the central system).
PROCEDURE DATE
(NEWBORN
HEARING
SCREENING)
Date of newborn hearing screening. If repeat screening is
indicated, this is the date of the first screen. If PROCEDURE
DATE is populated and is not with the reporting period, then the
group will be rejected.
If PROCEDURE DATE is populated and is before DATE OF
BIRTH (from MAT502), then the group will be rejected.
This data item is not relevant for stillbirths (this will not be
checked by the central system).
NEWBORN
HEARING
SCREENING
OUTCOME
(MATERNITY)
Page 127 of 163
Where data providers capture the information in a different
format or at a lower level, then they should be mapped to an
appropriate value stated in the national code list.
Copyright ©2013 Health and Social Care Information Centre
Maternity Services Data Set User Guidance
5.3.35.
V2.1
25/03/2013
MAT517 Newborn Blood Spot Screening Test
MAT517 Newborn Blood Spot Screening Test
Description
The group captures the mother’s response to the offer and result of the newborn blood
spot screening.
The offer should be captured for all registrable births (i.e. stillbirths and live births). The
result should only be provided for live births.
A mother may delay or change her response. Where data providers record both
responses, then two groups can be submitted, with OFFER DATE TIME reflecting the
two different days/times the decision was made/recorded. Where data providers do not
record all the “intermediate” decisions, then one group may be submitted with the
mother’s final decisions recorded in the OFFER STATUS.
The group captures the information on the blood spot screening process to the point the
blood sample is processed.
Results of the screening process (i.e. presence and absence of conditions) are outside
the scope of this data set; however, they are captured in the CYPHS secondary uses
data set.
Where samples are retaken on new blood spot cards, irrespective of reason, and data
providers record both results, then two groups can be submitted, with COMPLETION
DATE reflecting the two different days the sample was taken. Where data providers do
not record all the “intermediate” results (or where the two samples were taken on the
same day), then one group may be submitted with the final result recorded in the
RESULT STATUS.
The national standards on blood spot screening are developed by UK National Screening
Committee (UK NSC) and are available from:
http://newbornbloodspot.screening.nhs.uk/standards
Group Level Validation and Repeating Rules
The rules are fully described in the appropriate section for this group within the document
Maternity Data Set Technical Output Specification.
Additional Notes on Data Items
Data Item Name
Page 128 of 163
Additional Notes
Copyright ©2013 Health and Social Care Information Centre
Maternity Services Data Set User Guidance
LOCAL PATIENT
IDENTIFIER (BABY)
V2.1
25/03/2013
The data item will be captured for all live births and stillbirths.
The data set development process has highlighted that the Local
Patient Identifier (LPI) is captured for all registrable births.
This is the unique system identifier that identifies the baby. This
is the primary key that enables groups of data to be joined
together. As such this is a mandated item and the record will be
rejected if it is not included within this group.
Where multiple systems are used it is acceptable to include a
prefix to the Local Patient Identifier, which relates to the system.
The prefix enables each identifier to remains truly unique for all
submissions from an organisation.
Duplicate Local Patient Identifiers within the same submission
file will cause the entire file to be rejected. Duplicate Local
Patient Identifiers across multiple submission files will cause
both records to be rejected even if it is unique within each
submission file.
ACTIVITY OFFER
DATE
The date that the blood spot screening test was offered. This
item is not mandated, but if the Activity Offer Date and
Procedure Date are both blank (or the Offer Date is after the
Procedure Date or before the Date of Birth), then the group will
be rejected.
BLOOD SPOT CARD
COMPLETION DATE
The date that the blood spot screening test takes place. If
Completion Date is populated and is not with the reporting
period, then the group will be rejected.
If Completion Date is populated and is before Date Of Birth (from
MAT502), then the group will be rejected.
This data item is not relevant for stillbirths (this will not be
checked by the central system).
LABORATORY
IDENTIFIER
(NEWBORN BLOOD
SPOT SCREENING)
Page 129 of 163
Codes provided will be validated against the NHS Organisation
Data Service (ODS).
Where data providers capture site information in a different
format or at a lower level than the ODS codes, then they should
be mapped to an appropriate value stated in the national code
list.
Copyright ©2013 Health and Social Care Information Centre
Maternity Services Data Set User Guidance
BLOOD SPOT
SCREENING OFFER
STATUS
(PHENYLKETONURI
A)
BLOOD SPOT
SCREENING
STATUS
(PHENYLKETONURI
A)
BLOOD SPOT
SCREENING OFFER
STATUS (SICKLE
CELL DISEASE)
25/03/2013
Where data providers capture the information in a different
format or at a lower level, then they should be mapped to an
appropriate value stated in the national code list.
[IE] Ineligible - it is not possible to examine the baby so an offer
cannot be made. This may be due to:




Stillbirth
Neonatal death in hospital before routine discharge
Moved out of area before newborn examination offer was
possible
Moribund to the extent that offer of newborn examination
was inappropriate
Ineligible will not be applicable for cases where a baby is
transferred to a local NNU
[NR] No response to offer – the mother is offered the test (for
the baby), but a response is not provided. This may be due to:

BLOOD SPOT
SCREENING
STATUS (SICKLE
CELL
DISEASE)BLOOD
SPOT SCREENING
OFFER STATUS
(CYSTIC FIBROSIS)
V2.1

Communication issues (e.g. the test is offered by post,
but a response is not sent back.
Learning difficulty issues (e.g. or the mother is unable to
comprehend that a test is being offered).
BLOOD SPOT
SCREENING
STATUS (CYSTIC
FIBROSIS)BLOOD
SPOT SCREENING
OFFER STATUS
(CONGENITAL
HYPOTHYROIDISM)
BLOOD SPOT
SCREENING
STATUS
(CONGENITAL
HYPOTHYROIDISM)
BLOOD SPOT
SCREENING OFFER
STATUS (MEDIUM
CHAIN ACYL COA
DEHYDROGENASE
DEFICIENCY)
Page 130 of 163
Copyright ©2013 Health and Social Care Information Centre
Maternity Services Data Set User Guidance
V2.1
25/03/2013
5.3.36.
MAT602 Mother's Postpartum Discharge from Maternity
Services
MAT602 Mother's Postpartum Discharge from Maternity Services
Description
This group captures the information on a mother's postpartum discharge from the
maternity services, including her smoking status.
Group Level Validation and Repeating Rules
The rules are fully described in the appropriate section for this group within the
document Maternity Data Set Technical Output Specification.
Additional Notes on Data Items
Data Item Name
Additional Notes
LOCAL PATIENT
IDENTIFIER
(MOTHER)
This is the unique system identifier that identifies the mother.
This is the primary key that enables the groups of data to be
joined together. As such this is a mandated item and the record
will be rejected if it is not included within the group.
This is the unique system identifier that identifies the mother.
This is the primary key that enables groups of data to be joined
together. As such this is a mandated item and the record will be
rejected if it is not included within this group.
Duplicate Local Patient Identifiers within the same submission
file will cause the entire file to be rejected. Duplicate Local
Patient Identifiers across multiple submission files will cause
both records to be rejected even if it is unique within each
submission file.
DISCHARGE DATE
(MOTHER
MATERNITY
SERVICES)
Page 131 of 163
Date on which mother ceased to be cared for in maternity
services. If DISCHARGE DATE is not within the reporting
period, the group will be rejected.
Copyright ©2013 Health and Social Care Information Centre
Maternity Services Data Set User Guidance
SMOKING STATUS
(MOTHER AT END
OF PREGNANCY)
V2.1
25/03/2013
In regards to smoking status, systems should facilitate the
inclusion of corresponding booking appointment data items so
that the burden on data collection is minimised.
This data item captures the mother’s smoking status as
recorded at the end of the labour & delivery episode.
Where data providers capture the information in a different
format or at a lower level, then they should be mapped to an
appropriate value stated in the national code list.
Albeit in an aggregate form, an existing Information Standard,
Smoking and Pregnancy, captures the mother’s smoking status
at 3 stages:



12 months before pregnancy
Booking appointment
Delivery
The data submitted for the Smoking and Pregnancy DSCN is
independent of the data submitted for the MSDS, however, data
providers should ensure that both submissions are aligned. The
following mapping must be used:
Page 132 of 163
Smoking and
Pregnancy
MSDS national code list
Yes
[1] Current smoker
No
[2] Ex-smoker
No
[3] Non-smoker - history unknown
No
[4] Never smoked
Don’t Know
[9] Unknown
Copyright ©2013 Health and Social Care Information Centre
Maternity Services Data Set User Guidance
5.3.37.
V2.1
25/03/2013
MAT603 Mother’s Postpartum Readmission
MAT603 Mother’s Postpartum Readmission
Description
This group captures information on the mother’s hospital readmission(s), as an inpatient.
In the case of home births, this may be the first admission since the antenatal period.
Where an admission is made after the mother has been discharged from maternity
services, this admission is out of scope.
Group Level Validation and Repeating Rules
The rules are fully described in the appropriate section for this group within the
document Maternity Data Set Technical Output Specification.
Additional Notes on Data Items
Data Item Name
Additional Notes
LOCAL PATIENT
IDENTIFIER
(MOTHER)
This is the unique system identifier that identifies the mother.
This is the primary key that enables groups of data to be joined
together. As such this is a mandated item and the record will be
rejected if it is not included within this group.
Where multiple systems are used it is acceptable to include a
prefix to the Local Patient Identifier, which relates to the system.
The prefix enables each identifier to remains truly unique for all
submissions from an organisation.
Duplicate Local Patient Identifiers within the same submission
file will cause the entire file to be rejected. Duplicate Local
Patient Identifiers across multiple submission files will cause
both records to be rejected even if it is unique within each
submission file.
START DATE TIME
(HOSPITAL
PROVIDER SPELL
POSTPARTUM)
Date of in-patient readmission, to a hospital, in the postpartum
period (i.e. readmission after discharge following labour &
delivery). If DISCHARGE DATE is blank (or is after the end of
the reporting period) and START DATE is not within the
reporting period, the group will be rejected.
If DISCHARGE DATE is populated and START DATE is more
than 1 year before the DISCHARGE DATE, the group will be
rejected.
DISCHARGE DATE
TIME (HOSPITAL
PROVIDER SPELL
POSTPARTUM)
Date of in-patient discharge from hospital, after readmission in
the postpartum period. Validations if DISCHARGE DATE is
populated:
If it is before the start of the reporting period, the group will be
rejected.
If it is after the end of the reporting period a warning will be
output.
If it is before the START DATE, the group will be rejected.
Page 133 of 163
Copyright ©2013 Health and Social Care Information Centre
Maternity Services Data Set User Guidance
5.3.38.
V2.1
25/03/2013
MAT901 Complicating STIs at Booking
MAT901 Complicating STIs at Booking
Description
This group specifically captures information on sexually transmitted infections (STIs)
diagnosed before the start of this antenatal pathway (i.e. prior to the booking
appointment).
Group Level Validation and Repeating Rules
This group is anonymous and is therefore sent without any patient identifiers (this is to
ensure the data set complies with NHS Trusts and Primary Care Trusts (Sexually
Transmitted Diseases) Direction 2000131.)
Consequently there can be many MAT901 groups in a transmission file and the central
data warehouse will have no way of detecting any duplicates.
Data providers are urged to take care when submitting anonymous groups to ensure that
there are no duplicates.
Additional Notes on Data Items
Data Item Name
Additional Notes
APPOINTMENT
DATE (FORMAL
ANTENATAL
BOOKING)
Referred to as the Booking Appointment, the date on which the
assessment for health and social care needs, risks and choices
and arrangements made for antenatal care as part of the
pregnancy episode was completed. If APPTDATE is not within
the reporting period, the group will be rejected.
MATERNITY
COMPLICATING
SEXUALLY
TRANSMITTED
INFECTION
DIAGNOSIS
(MOTHER AT
BOOKING)
As identified at the Booking Appointment and based on the
woman's past medical history, the diagnosis of a sexually
transmitted infection presenting a risk or complicating factor for
this pregnancy.
NHS Trusts and Primary Care Trusts (Sexually Transmitted Diseases) Direction 2000 –
[http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsLegislation/DH_4083027]
131
Page 134 of 163
Copyright ©2013 Health and Social Care Information Centre
Maternity Services Data Set User Guidance
5.3.39.
V2.1
25/03/2013
MAT903 Mother's Syphilis Screening Test
MAT903 Mother's Syphilis Screening Test
Description
Routinely, blood samples for infectious diseases and inherited blood disorders are
offered and taken at the booking appointment. However, blood tests could be
undertaken at any time during the pregnancy.
According to NICE CG62 Antenatal Care, blood samples should ideally be taken within
10 weeks gestation132. However, it may be that, for whatever reason, the blood samples
are taken later and possibly even just before the onset of labour. Irrespective of timing, if
a data provider takes blood samples the appropriate information will be captured in this
section. At the reporting stage, the ‘blood test sample date’ data item will indicate how
late the tests were undertaken.
Group Level Validation and Repeating Rules
This group is anonymous and is therefore sent without any patient identifiers (this is to
ensure the data set complies with NHS Trusts and Primary Care Trusts (Sexually
Transmitted Diseases) Direction 2000133.)
Consequently there can be many MAT903 groups in a transmission file and the central
data warehouse will have no way of detecting any duplicates.
Data providers are urged to take care when submitting anonymous groups to ensure that
there are no duplicates.
Additional Notes on Data Items
Data Item Name
Additional Notes
ACTIVITY OFFER
DATE
The date that the syphilis screening test was offered. This item
is not mandated, but if the Activity Offer Date and Sample Date
are both blank (or the Activity Offer Date is after the Sample
Date or outside of the reporting period), then the group will be
rejected.
OFFER STATUS
(SCREENING
MOTHER SYPHILIS)
[01] Offered and undecided is a transient value, which will, in
most cases, be superseded by [02] Offered and declined or [03]
Offered and accepted.
The only time where [01] Offered and undecided should be
submitted is where a mother considers the screening offer but is
unable to confirm how she wishes to progress before the
submission window closes for the reporting period that contains
the Date of Offer. (ie. This is the last chance for the data
provider to submit this group before it will be rejected due to
being for the wrong reporting period).
132
England. NICE (Corrected Jun 2008) CG62 Antenatal Care: Full Guideline, London: RCOG Press, pp. 78
[http://www.nice.org.uk/nicemedia/live/11947/40145/40145.pdf]
133
NHS Trusts and Primary Care Trusts (Sexually Transmitted Diseases) Direction 2000
[http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsLegislation/DH_4083027]
Page 135 of 163
Copyright ©2013 Health and Social Care Information Centre
Maternity Services Data Set User Guidance
V2.1
25/03/2013
BLOOD TEST
SAMPLE DATE
(SCREENING
MOTHER SYPHILIS)
Local systems may have been developed in such a manner that
the blood test sample date is only captured once. In this case,
this single date needs to be cascaded to all the groups relating
to the blood test sample.
INVESTIGATION
RESULT
(SCREENING
MOTHER SYPHILIS)
[03] Test process incomplete should be used in any instance
where a sample has been taken and the testing process for that
sample could not be completed (which identifies a failure or
delay in the screening process). This may be because


Page 136 of 163
The sample was lost in transit; or
The sample received at the laboratory was inadequate.
Copyright ©2013 Health and Social Care Information Centre
Maternity Services Data Set User Guidance
5.3.40.
V2.1
25/03/2013
MAT905 Mother's HIV Screening Test
MAT905 Mother's HIV Screening Test
Description
Routinely, blood samples for infectious diseases and inherited blood disorders are
offered and taken at the booking appointment. However, blood tests could be
undertaken at any time during the pregnancy.
According to NICE CG62 Antenatal Care, blood samples should ideally be taken within
10 weeks gestation134. However, it may be that, for whatever reason, the blood samples
are taken later and possibly even just before the onset of labour. Irrespective of timing, if
a data provider takes blood samples the appropriate information will be captured in this
section. At the reporting stage, the ‘blood test sample date’ data item will indicate how
late the tests were undertaken.
Group Level Validation and Repeating Rules
This group is anonymous and is therefore sent without any patient identifiers (this is to
ensure the data set complies with NHS Trusts and Primary Care Trusts (Sexually
Transmitted Diseases) Direction 2000135.)
Consequently there can be many MAT903 groups in a transmission file and the central
data warehouse will have no way of detecting any duplicates.
Data providers are urged to take care when submitting anonymous groups to ensure that
there are no duplicates.
Additional Notes on Data Items
Data Item Name
Additional Notes
ACTIVITY OFFER
DATE
The date that the HIV screening test was offered. This item is
not mandated, but if the Activity Offer Date and Sample Date
are both blank (or the Activity Offer Date is after the Sample
Date or outside of the reporting period), then the group will be
rejected.
134
England. NICE (Corrected Jun 2008) CG62 Antenatal Care: Full Guideline, London: RCOG Press, pp. 78
[http://www.nice.org.uk/nicemedia/live/11947/40145/40145.pdf]
135
TrustNHS Trusts and Primary Care Trusts (Sexually Transmitted Diseases) Direction 2000
[http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsLegislation/DH_4083027]
Page 137 of 163
Copyright ©2013 Health and Social Care Information Centre
Maternity Services Data Set User Guidance
OFFER STATUS
(SCREENING
MOTHER HUMAN
IMMUNODEFICIENC
Y VIRUS)
V2.1
25/03/2013
[01] Offered and undecided is a transient value, which will, in
most cases, be superseded by [02] Offered and declined or [03]
Offered and accepted.
The only time where [01] Offered and undecided should be
submitted is where a mother considers the screening offer but is
unable to confirm how she wishes to progress before the
submission window closes for the reporting period that contains
the ACTIVITY OFFER DATE. (ie. This is the last chance for the
data provider to submit this group before it will be rejected due
to being for the wrong reporting period).
If she subsequently confirms her wishes, then the group should
be resent with the ACTIVITY OFFER DATE set to the date the
mother made the decision.
[PN] Test not required - prior diagnosis will be captured where a
healthcare professional is aware, through verifiable sources,
that the mother is already diagnosed with the condition (in which
case a screening test is not necessary). This is as per the
‘Infectious diseases in pregnancy screening programme
standards’136
BLOOD TEST
SAMPLE DATE
(SCREENING
MOTHER HUMAN
IMMUNODEFICIENC
Y VIRUS)
Local systems may have been developed in such a manner that
the blood test sample date is only captured once. In this case,
this single date needs to be cascaded to all the groups relating
to the blood test sample.
INVESTIGATION
RESULT
(SCREENING
MOTHER SYPHILIS)
[03] Test process incomplete should be used in any instance
where a sample has been taken and the testing process for that
sample could not be completed (which identifies a failure or
delay in the screening process). This may be because


The sample was lost in transit; or
The sample received at the laboratory was inadequate.
Infectious diseases in pregnancy screening programme standards’ v5 (June 2010), Section 2 (page 9)
[http://infectiousdiseases.screening.nhs.uk/standards]
136
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MAT906 Maternity STI Diagnosis
MAT906 Maternity STI Diagnosis
Description
This group specifically captures information on sexually transmitted infections (STIs)
diagnosed during the pregnancy outside the routine antenatal screening process.
Where a HIV diagnosis is through the routine antenatal screening process, the diagnosis
will be captured in its appropriate group. These diagnoses must not be repeated in this
group.
Group Level Validation and Repeating Rules
This group is anonymous and is therefore sent without any patient identifiers (this is to
ensure the data set complies with NHS Trusts and Primary Care Trusts (Sexually
Transmitted Diseases) Direction 2000137.)
Consequently there can be many MAT906 groups in a submission and the central data
warehouse will have no way of detecting any duplicates.
Data providers are urged to take care when submitting anonymous groups to ensure that
there are no duplicates.
Additional Notes on Data Items
Data Item Name
Additional Notes
DIAGNOSIS DATE
The person property observed date for diagnostic observations
recorded about a mother.
MATERNITY
SEXUALLY
TRANSMITTED
INFECTION
DIAGNOSIS
(CURRENT
PREGNANCY)
Where data providers capture diagnoses at a lower level then
they should be mapped to an appropriate value stated in the
national code list.
137
TrustNHS Trusts and Primary Care Trusts (Sexually Transmitted Diseases) Direction 2000
[http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsLegislation/DH_4083027]
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5.4. Centrally derived data items
The MSDS Technical Output Specification only defines the data items data providers need to submit
to the central data warehouse. This data set can be manipulated by the central data warehouse, via
mathematical calculation or by accessing other national reference data, to provided additional
derived data items.
These additional derived data items are detailed in the MSDS Extract Specification.
The purpose of deriving these additional data items is:



To reassure users and stakeholders that the data set has not omitted any ‘high priority’ data
items that are routinely captured / derived for clinical care (and therefore included in clinical
systems).
To provide calculations for ‘high priority’ data items, so that users and stakeholders are aware
of how they will be formulated.
To derive additional data items, based upon “identifiable” data items, such as postcode, that
can then be used within anonymised and pseudonymised reporting.
The derived data items are not part of the ISB approved MSDS (since they do not have any
implications for data providers), so any changes to these data items will not require any approval
from ISB.
Global
Number
Input/
Data Item Name
Derived/
External
Source
17205340 D
INTERVENTION
FREE BIRTH
Additional information
The derivation of this data item is based on
the following circumstances:

17205350 D
NORMAL DELIVERY
(MCWP)
Whether labour was induced (does not
include membrane sweep)
 Whether labour was augmented
(amniotomy or oxytocin)
 The method of delivery (e.g. caesarean,
spontaneous vaginal, assisted)
 Whether pain relief was administered
(where pain relief is water immersion,
complementary therapies, paracetamol,
TENS or inhalational analgesia, they will
not be regarded as significant
interventions)
 Whether anaesthesia was administered
 The method of delivering placenta
 Whether episiotomy was performed
This data item is based on the Maternity Care
Working Party’s (MCWP) definition of ‘Normal
labour and birth’, as highlighted in ‘Making
normal birth a reality’138. A ‘normal birth and
labour’ is defined as a pregnancy:

Without induction
138
Making normal birth a reality (Nov 2007), Page 5 [http://www.rcog.org.uk/files/rcog-corp/uploadedfiles/JointStatmentNormalBirth2007.pdf]
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Global
Number
Input/
Data Item Name
Derived/
External
Source
V2.1
25/03/2013
Additional information




Without the use of instruments (i.e.
forceps or ventouse)
Not by caesarean section
Without general, spinal or epidural
anaesthetic Before or during delivery
Without episiotomy
The MCWP has adopted the definition of
‘normal delivery’, with a clarification over
episiotomy, as previously used by the HSCIC
and highlighted in section 2.1 of the ‘NHS
Maternity Statistics, England 2005-06’139
publication, and in previous years going back
to 2002-03. The HSCIC defined it a ‘Normal
delivery’.
All derived data items and their corresponding
calculation are shown in the ‘Maternity
Services Secondary Uses Data Set Centrally
Derived Data items’ spreadsheet.140
17206250 D
RESUSCITATION
AT BIRTH
The data item, which captured information on
resuscitation immediately after birth, is
derived from data items:
- NEONATAL RESUSCITATION METHOD
- NEONATAL RESUSCITAATION DRUG OR
FLUID
The three values are defined as:

17206970 D
LENGTH OF STAY
IN HOSPITAL
AFTER DELIVERY
(MOTHER)
None - no resuscitation required or
attempted
 Basic - Any resuscitative measure using
mask inflation
 Advanced - where a baby is given:
o mask inflation and
o Another modality (which could be
drugs)
A derived data item that captures the period
between end of delivery (i.e. end of third
stage) and discharge to community services
(from an NHS Unit).
In the event of a home birth (planned or
139
Normal delivery definition - NHS Maternity Services, 2005-06, Section 2.1 [http://www.ic.nhs.uk/statistics-and-datacollections/hospital-care/maternity/nhs-maternity-statistics-2005-06]
140
Maternity Services Secondary Uses Data Set Centrally Derived Data items spread sheet
[http://www.ic.nhs.uk/maternityandchildren/maternity]
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Number
Input/
Data Item Name
Derived/
External
Source
V2.1
25/03/2013
Additional information
unplanned) and the mother is not transferred
to an NHS unit, this data item will be null.
5.5. System Conformance to the Standard
To assist data providers in assessing how well local electronic systems map to the MSDS, a System
Conformance Checklist has been produced. The System Conformance Checklist is a high-level
document that data providers use to review local systems against each data item referred to in the
data set. It is for self-assessment purposes only, and will ideally be completed jointly by a
number of different professionals, e.g. service leads, clinicians, frontline end users, business
analysts, information analysts and system suppliers. Full instructions for completion are within the
document.
The National Data Sets Service recommends the use of Global Numbers (as specified in the MSDS
Technical Output Specification) in local systems and as part of reporting. Data providers have
reported that these are useful in their data warehouses in the labelling of functions and routines to
call for the data items. Global Numbers may also be useful added to system reports and may also
help with extracts and messages which are used to populate local data warehouses.
Sites are also recommended to procure missing field reports based on the items in the conformance
pro forma. This will particularly assist in ensuring the mandated data items are populated where
applicable. It will also highlight the missing functionality for collection of optional data items that the
data providers may wish to work towards for local use and which may be mandated at a future date.
5.6. Classification Systems
5.6.1. ICD-10 and OPCS
For data submission purposes, data providers should submit the national codes specified in the
MSDS Technical Output Specification. Commissioners and service providers make use of existing
national and international classification systems such as the International Statistical Classification of
Diseases and Related Health Problems (ICD)141 revision 10, and the Office of Population Censuses
and Surveys' Classification of Surgical Operations, version 4 (OPCS-4)142.
The MSDS does not require data providers to submit any ICD-10 or OPCS-4 code to the central data
warehouse, therefore these classification systems are deemed outside the scope of this data set.
Where data providers convert their clinical data to ICD-10 or OPCS-4 codes, the implementation of
the MSDS should not interfere with this. Data providers should map the ICD-10 or OPCS-4 code to
the MSDS national code for submission to the central data warehouse.
Data providers should not re-model existing processes in order that local IT systems only capture the
MSDS national codes.
141
ICD [http://www.who.int/classifications/icd/en]
142
OPCS
[http://www.connectingforhealth.nhs.uk/systemsandservices/data/clinicalcoding/codingstandards/opcs4/index_html]
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5.6.2. SNOMED CT
To support interoperability between systems, SNOMED Clinical Terms (SNOMED CT)143 is a clinical
terminology system aimed at clinical IT systems. The MSDS is an output data set that only re-uses
clinical data, as opposed to specifying a clinical data standard. As the data set does not contain any
clinical coding SNOMED CT is deemed out of scope. However, this could be reviewed again further
in terms of any subsequent changes and for the purposes of any future or subsequent releases.
5.7. Linking events in the care pathway using NHS number
The MSDS is one of three data sets of the overarching Maternity and Children’s Data Set.
All three data sets capture data at patient level and share a single data warehouse. Each data set
also encourages the use of NHS number as a patient identifier. If data providers submit data sets
with a high coverage of validated NHS number, it becomes increasingly feasible for the central data
warehouse to link data across the three data sets.
There will be occasions where NHS number is unavailable and in such cases, the local patient
identifier will be used for data linkage purposes. In the absence of the local patient identifier, data
linkage will be impossible and so these submitted records will be rejected.
143
SNOMED CT [http://www.connectingforhealth.nhs.uk/systemsandservices/data/snomed ]
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6. Alignment with existing and proposed ISB
standards
The MSDS will not supersede or replace any existing ISB information standards. Nevertheless, the
MSDS does share similar requirements does share similar requirements with other approved ISB
information standards:







CAMHS Secondary Uses Data Set.
CYPHS Secondary Uses Data Set.
Commissioning Data Set (CDS).
Neonatal Critical Care Minimum Data Set (NCCMDS).
The NHS Numbers for Babies Data Set (NN4B) - not an ISB approved data set.
Smoking and Pregnancy Information Standard.
72 Hour Newborn & Infant Physical Examination (NIPE) Screening Data Set – not yet
approved.
It is not feasible, at this time, for MSDS to re-use data from other data sets because:


The MSDS will only share a data warehouse with the other two Maternity and Children’s data
sets and the MSDS will only therefore be linked with these two data sets.
The MSDS will store data in a pseudonymised form using an encryption key coded
specifically for the Maternity and Children’s data sets.
Where the MSDS has requirements (i.e. data items) in line with other data sets, data providers
should endeavour to capture the data item only once and re-use it for each relevant data set. It is
recommended that data is collected at the deepest granular level, and on submission is mapped to
meet each data set requirement.
The MSDS captures information from the point of baby’s conception to the point of child health
services referral (i.e. maternity services / neonatal services discharge) and the CYPHS Secondary
Uses Data Set commences at the point of baby’s referral to Child Health services (and ceases at age
eighteen). After 18 years, the data warehouse will provide the capacity to analyse how a person’s
pregnancy care affected their childhood and adolescent years.
The link between MSDS and CAMHS Secondary Uses Data Set is less strong, but will enable the
comparison of outcomes for mothers with a history within CAMHS and also help to track and
compare the history of children and young people who enter CAMHS.
6.1. CAMHS Secondary Uses Data Set
The MSDS does not share any data items with CAMHS Secondary Uses Data Set, apart from the
NHS number.
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6.2. CYPHS Secondary Uses Data Set
Not including the NHS number, there are six data items that are replicated in CYPHS Secondary
Uses Data Set.
MSDS
CYPHS
NEWBORN HEARING SCREENING OUTCOME
01 Clear response no follow up required
01 Clear response no follow up required
02 Clear response targeted follow-up
required
02 Clear response targeted follow-up required
03 No clear response bilateral referral
04 No clear response unilateral referral
03 No clear response bilateral referral
04 No clear response unilateral referral
98 Incomplete
05 Incomplete - screening contraindicated
06 Incomplete - baby deceased
07 Incomplete - baby unsettled
08 Incomplete - parent declined screen
09 Incomplete - appointment missed
10 Incomplete - lack of service capacity
11 Incomplete - lost contact
12 Incomplete - out of screening coverage
13 Incomplete - late entry
14 Incomplete - equipment malfunction
15 Incomplete - equipment not available
16 Incomplete - parent withdrew consent
Both data sets capture the outcome of the newborn hearing screening although MSDS captures
the data in added granularity. From an alignment perspective, all the MSDS values will map to
the CYPHS Secondary Uses Data Set values, but not vice-versa.
The screening outcome data item is repeated across the two data sets so that appropriate service
providers can submit data to the appropriate data set.
BLOOD SPOT SCREENING ADMINISTRATIVE RESULT STATUS (PHENYLKETONURIA)
BLOOD SPOT SCREENING ADMINISTRATIVE RESULT STATUS (SICKLE CELL DISEASE)
BLOOD SPOT SCREENING ADMINISTRATIVE RESULT STATUS (CYSTIC FIBROSIS)
BLOOD SPOT SCREENING ADMINISTRATIVE RESULT STATUS (CONGENITAL
HYPOTHYROIDISM)
BLOOD SPOT SCREENING ADMINISTRATIVE RESULT STATUS (MEDIUM CHAIN ACYL COA
DEHYDROGENASE DEFICIENCY)
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MSDS
CYPHS
01 Specimen received in laboratory
01 Specimen received in laboratory
02 Screening declined
02 Screening declined
03 Further sample required
03 Further sample required
25/03/2013
04 Condition not suspected
05 Carrier
06 Carrier of other haemoglobin
07 Condition not suspected, other disorders
follow up
08 Condition suspected
09 Not screened/screening incomplete
The CYPHS Secondary Uses Data Set consists of the data items with a wider value list, but
includes the three values as per the MSDS.
The screening outcome data item is repeated across the two data sets so that appropriate service
providers can submit data to the appropriate data set.
6.3. Commissioning Data Set (CDS)
The Commissioning Data Set (CDS)144 is used by:


Commissioners to pay service providers (e.g. CCGs and the NHSCB making payments to
acute Trusts).
The HSCIC to produce Hospital Episode Statistics (HES) reports.
Version 6 of the data set, implemented in 2007, separates data items into five activity areas:





Accident & Emergency
Care activity
Admitted patient care
Elective admission list – end of period census types
Elective admission list – event during period types
Each area consists of a small number of data set types. Using the ‘Finished Birth Episode’ and
‘Finished Delivery Episode’ data set types from the ‘Admitted Patient Care’ activity area, some CDS
data items align to the MSDS.
NB. MSDS is independent of CDS, so data providers will need to continue with existing CDS data
submission protocols.
144
CDS
[http://www.datadictionary.nhs.uk/web_site_content/cds_supporting_information/commissioning_data_set_overview.asp?sh
ownav=1]
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CDS V6.2145
MSDS
Data Item Name
Data Item Name
Data Group
Data Set Type
LOCAL PATIENT
IDENTIFIER (MOTHER)
Local patient identifier
Patient identity
Finished del. ep.
Local patient identifier
(mother)
Birth occurrence
person identity
– (mother)
Finished birth ep.
ORGANISATION CODE
(LOCAL PATIENT
IDENTIFIER (MOTHER))
Organisation code (Local
patient identifier)
Patient identity
Finished del. ep.
Organisation code (Local
patient identifier (Mother))
Birth occurrence
person identity –
(mother)
Finished birth ep.
NHS number
Patient identity
Finished del. ep.
NHS number (mother)
Birth occurrence
person identity –
(mother)
Finished birth ep.
NHS number status
indicator
Patient identity
Finished del. Ep.
NHS number status
indicator (mother)
Birth occurrence
person identity –
(mother)
Finished birth ep.
Postcode of usual address
Patient identity
Finished del. Ep.
Postcode of usual address
(mother)
Birth occurrence
person identity –
(mother)
Finished birth ep.
Organisation code (PCT of
residence)
Patient identity
Finished del. ep.
Organisation code (PCT of
residence (mother))
Birth occurrence
person identity –
(mother)
Finished birth ep.
Person birth date
Patient identity
Finished del. ep
Person birth date (mother)
Birth occurrence
person identity –
(mother)
Finished birth ep.
NHS NUMBER
(MOTHER)
NHS NUMBER STATUS
INDICATOR (MOTHER)
POSTCODE OF USUAL
ADDRESS (MOTHER)
Derivable from
POSTCODE OF USUAL
ADDRESS (MOTHER)
PERSON BIRTH DATE
(MOTHER)
145
CDS V6.2 [http://www.datadictionary.nhs.uk/web_site_content/cds_supporting_information/cds_version_62_type_list.asp?shownav=1]
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MSDS
Data Item Name
Data Item Name
Data Group
Data Set Type
NHS NUMBER (BABY)
NHS number (baby)
Birth occurrence Person patient
identity (baby)
Finished del. ep.
NHS number
Patient identity
Finished del. ep
NHS number status
indicator (baby)
Birth occurrence Person patient
identity (baby)
Finished del. ep.
NHS number status
indicator
Patient identity
Finished del. ep
Person birth date (baby)
Birth occurrence Person patient
identity (baby)
Finished del. ep.
Person birth date
Patient identity
Finished del. ep
Person gender current
(baby)
Birth occurrence –
Person
characteristics –
(baby)
Finished del. ep.
Person gender current
Patient
characteristics
Finished del. ep
Birth occurrence –
Person
characteristics –
(baby)
Finished del. ep.
Patient
characteristics
Finished birth ep.
NHS NUMBER STATUS
INDICATOR (BABY)
DATE TIME OF BIRTH
(BABY)
SEX (BABY)
PREGNANCY OUTCOME Live or still birth
(CURRENT FETUS)
10
Live birth
20
Stillbirth
30
Miscarriage
40
Termination of
Pregnancy < 24weeks
50
Termination of
Pregnancy >= 24weeks
Live or still birth
XX Other inc vanishing/
papyraceous twin,
ectopic
Data must be captured in line with MSDS to deliver both data set requirements. If data is only
captured as per CDS, the MSDS cannot be fully delivered.
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MSDS
Data Item Name
Data Item Name
Data Group
Data Set Type
BIRTH WEIGHT
Birth weight
Birth occurrence –
Person
characteristics –
(baby)
Finished del. ep.
Birth weight
Patient
characteristics
Finished birth ep.
Discharge date (Hospital
provider spell)
Hospital provider
spell – Admission
characteristics
Finished del. ep.
DISCHARGE DATE TIME
(MOTHER POST
DELIVERY HOSPITAL
PROVIDER SPELL)
Data must be captured in line with MSDS to deliver both data set requirements. If data is only
captured as per CDS, the MSDS cannot be fully delivered.
Transfer start date time
(neonatal unit)
Critical care start date
Critical care start time
Neonatal critical
care period
Finished del. ep.
Neonatal critical
care period
Finished del. ep.
Finished birth ep.
Finished birth ep.
The two data items do not directly align. The CDS captures critical care irrespective of place of
care, although this is likely to be in a Neonatal Unit. The MSDS only captures admissions to
Neonatal Units.
GESTATIONAL LENGTH
(AT BIRTH)
Gestation length (at
delivery)
Captured in days
Captured in weeks
Neonatal critical
care period
Finished birth ep.
Data must be captured in line with MSDS to deliver both data set requirements. If data is only
captured as per CDS, the MSDS cannot be fully delivered.
ORGANISATION CODE
(GMP PRACTICE OF
MOTHER)
General medical practice
code (patient registration)
GP registration
Derivable - CDS data item
can be derived by a
perfuming a count on
MSDS data item NHS
NUMBER (BABY).
Number of babies
Pregnancy – Activity Finished del. ep.
characteristics
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CDS V6.2145
MSDS
Data Item Name
Data Item Name
Data Group
Data Set Type
APPOINTMENT DATE
(FORMAL ANTENATAL
BOOKING)
First antenatal assessment
date
Antenatal care
Finished del. ep.
Derivable – from
ORGANISATION CODE
(GMP PRACTICE OF
MOTHER)
General medical
practitioner practice
(antenatal care)
Antenatal care –
person group
Finished del. ep.
DELIVERY PLACE
CHANGE REASON
Delivery place change
reason
Antenatal care –
location group
Finished del. ep.
DELIVERY PLACE TYPE
(INTENDED)
Delivery place type
(intended)
Antenatal care –
location group
Finished del. ep.
Hospital / labour
delivery
Finished del. ep.
ANAESTHESIA TYPE IN Anaesthetic given during
LABOUR AND DELIVERY labour or delivery:
(repeated for each
anaesthesia type)
01 General anaesthetic
02 Epidural or caudal
anaesthetic
03 Spinal anaesthetic
09 Pudendal block
anaesthetic
97 Other anaesthetic or
analgesic only










Finished birth ep.
Finished birth ep.
Finished birth ep.
Finished birth ep.
General anaesthetic
Epidural or caudal anaesthetic
Spinal anaesthetic
General anaesthetic and
epidural or caudal anaesthetic
General anaesthetic and spinal
anaesthetic
Epidural or caudal and spinal
anaesthetic
Other anaesthetic or analgesic
only
Other anaesthetic
No analgesic or anaesthetic
administered
Not known: a validation error
98 No anaesthetic
administered
Data must be captured in line with MSDS to deliver both data set requirements. The MSDS data
item is a repeating data item, and so can deliver all the CDS values. If data is only captured as per
CDS, the MSDS cannot be fully delivered.
Derivable - The CDS data
item can be derived from
MSDS data item ONSET
OF ESTABLISHED
LABOUR DATE TIME
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Gestation length (labour
onset)
Hospital / labour
delivery
Finished del. ep.
Finished birth ep.
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25/03/2013
CDS V6.2145
MSDS
Data Item Name
Data Item Name
Data Group
Data Set Type
Derivable - The CDS data
item is derivable from the
following MSDS data
items:
Labour or delivery onset
method
Hospital / labour
delivery
Finished del. ep.
Hospital / labour
delivery
Finished del. ep.
Birth occurrence
Finished del. ep.
 Rupture of membranes
method
 Onset of established labour
date time
 Procedure date time
(caesarean section)
 Date time of decision to
deliver
 Medical induction of labour
method
Finished birth ep.
 Spontaneous
 Any caesarean section
carried out before the onset
of labour or a planned
elective caesarean section
carried out immediately
following the onset of
labour, when the decision
was made before labour
 Surgical induction; by
amniotomy
 Medical induction
 Combination of surgical
induction and medical
induction
 Not known: a validation
error
DATE TIME OF BIRTH
(BABY)
Delivery date
BIRTH ORDER
Birth order
Finished birth ep.
Finished birth ep.
DELIVERY METHOD
(CURRENT BABY)
Delivery method
GESTATIONAL LENGTH
(AT BIRTH)
Gestation length
(assessment)
Captured in days
Captured in days
Birth occurrence
Finished del. ep.
Finished birth ep.
Birth occurrence
Finished del. ep.
Finished birth ep.
Data must be captured in line with MSDS to deliver both data set requirements. The MSDS derives
gestational length in days whereas CDS captures it in weeks. If data is only captured as per CDS,
the MSDS cannot be fully delivered.
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MSDS
Data Item Name
Data Item Name
Data Group
Data Set Type
NEONATAL
RESUSCITATION
METHOD
Resuscitation method
Birth occurrence
Finished birth ep.
01 Oxygen
02 Intermittent Positive
Pressure Ventilation
(IPPV) Mask
03 Intermittent Positive
Pressure Ventilation
(IPPV) tube
04 Chest compression
NEONATAL
RESUSCITATION DRUG
OR FLUID
 Positive pressure nil, drugs
nil
 Positive pressure nil, drugs
administered
 Positive pressure by mask,
drugs nil
 Positive pressure by mask,
drugs administered
 Positive pressure by
endotracheal tube, drugs nil
 Positive pressure by
endotracheal tube, drugs
administered
 Not applicable (e.g.
stillborn, where no method
of resuscitation was
attempted)
 Not known: a validation
error
01 Adrenaline
02 Sodium bicarbonate
03 Blood
04 0.9% sodium chloride
05 Glucose solution
Data must be captured in line with MSDS to deliver both data set requirements. If data is only
captured as per CDS, the MSDS cannot be fully delivered.
6.4. Neonatal Critical Care Minimum Data Set
Mandated in April 2006, the Neonatal Critical Care Minimum Data Set (NCCMDS) captures
information on babies receiving Neonatal Critical Care in a Neonatal Intensive Care Unit (NICU),
Maternity Ward or a Neonatal Transitional Care Ward.
The MSDS only captures information on babies admitted to a Neonatal Unit (NNU).
The two data sets are therefore not directly comparable, although there is a strong commonality as
they both capture information on NNU admissions. Where a data provider wishes to reuse data for
multiple data sets, they should ensure that only NNU admissions are submitted as part of the MSDS.
Although the NCCMDS is a ‘stand-alone’ Information Standard, it is integrated within CDS. The
NCCMDS data items are part of the ‘Neonatal critical care’ data group of CDS.
NB. MSDS is independent of NCCMDS, so data providers will need to continue with existing
NCCMDS data submission protocols.
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NCCMDS v3.0146
DATE TIME OF BIRTH (BABY)
Person birth date
TRANSFER START DATE TIME
(NEONATAL UNIT)
Critical care start date
GESTATIONAL LENGTH (AT BIRTH)
Gestation length (at delivery)
Captured in days
Captured in weeks
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Critical care start time
Data must be captured in line with MSDS to deliver both data set requirements. The MSDS
derives gestational length in days whereas NCCMDS captures it in weeks. If data is only
captured as per NCCMDS, the MSDS cannot be fully delivered
6.5. NN4B Data Set
In 2002, to deliver the NHS Number for Babies (NN4B) project, every maternity unit in England and
Wales began submitting the Birth Notification Data Set to the NN4B Central Issuing Service (CIS) to
obtain NHS numbers for newborn babies. NN4B is not an ISB approved data set but has been
implemented across the NHS.
To minimise data collection duplication, many maternity systems have a direct link to the CIS in order
to request and receive NHS numbers.
MSDS
NN4B Data Set v4.0147
NHS NUMBER (BABY)
NHS number
DATE TIME OF BIRTH (BABY)
Date of Birth
Delivery Time
SEX (BABY)
Sex
146
NCCMDS, data set specification v3.0 [http://www.isb.nhs.uk/documents/isb-0075/dscn-142006/0075142006fullsubappd.pdf]
147
NN4B data set v4.0 [http://www.connectingforhealth.nhs.uk/industry/docs/nn4b/nn4bdata set.pdf]
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NN4B Data Set v4.0147
PREGNANCY OUTCOME (CURRENT
FETUS)
Live or still birth
10 Live birth
20 Stillbirth
30 Miscarriage





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Live
Stillbirth, ante-partum
Stillbirth, intra-partum
Stillbirth, indeterminate
Dead
40 Termination of Pregnancy < 24weeks
50 Termination of Pregnancy >= 24weeks
XX Other inc vanishing/papyraceous twin, ectopic
Systems can be developed so that they capture data at the deepest granular level and, thereafter,
through a mapping exercise, deliver the requirements of each data set.
BIRTH WEIGHT
Birth weight
GESTATIONAL LENGTH (AT BIRTH)
Gestation length (weeks)
Captured in days
Captured in weeks
Data must be captured in line with MSDS to deliver both data set requirements. The MSDS
derives gestational length in days whereas NN4B captures it in weeks. If data is only captured as
per NN4B, the MSDS cannot be fully delivered
BIRTH ORDER
Birth order in this confinement (if multiple)
ORGANISATION SITE CODE (ACTUAL
PLACE OF DELIVERY)
Organisation code
The organisation code can be derived from the organisation site code
DELIVERY PLACE TYPE (ACTUAL)
Delivery place type
NHS NUMBER (MOTHER)
Mothers’ NHS number
PERSON BIRTH DATE (MOTHER)
Mothers’ date of birth
ORGANISATION CODE (GMP PRACTICE
OF MOTHER)
National Practice code
6.6. Smoking and Pregnancy Data Set
The Smoking and Pregnancy ISN was implemented in April 2003 and requires hospital Trusts to
send aggregate returns on smoking status for all women giving birth under their care. The key
differences with the MSDS are:
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MSDS captures smoking status for all pregnant women, irrespective of the pregnancy
outcome, not just those with a registrable birth.
MSDS captures data at patient-level whereas the Smoking and Pregnancy standard captures
aggregate data.
If data provider systems can capture data for MSDS values, it will also be possible to derive the
majority of requirements of the Smoking and Pregnancy Information Standard.
MSDS
Smoking and Pregnancy Data Set
SMOKING STATUS (MOTHER AT
BOOKING)
Did the patient smoke cigarettes at all in the 12
months before the start of pregnancy? (Mapping
to MSDS in brackets)
01 Current smoker
02 Ex-smoker - Stopped after conception



Yes (01, 02, 03)
No (04, 06)
Don’t know (05, 09)
03 Ex-smoker - Stopped between conception and 12
months before conception
04 Ex-smoker - Stopped more than 12 months before
conception
05 Non-smoker - history unknown
06 Never smoked
09 Unknown
SMOKING STATUS (MOTHER AT
BOOKING)
01 Current smoker
02 Ex-smoker - Stopped after conception
Is / was the patient a smoker at the time of
booking? (Mapping to MSDS in brackets)



Yes (01)
No (02, 03, 04, 05, 06)
Don’t know (09)
03 Ex-smoker - Stopped between conception and 12
months before conception
04 Ex-smoker - Stopped more than 12 months before
conception
05 Non-smoker - history unknown
06 Never smoked
09 Unknown
SMOKING STATUS (MOTHER AT END OF
PREGNANCY)
1
Current smoker
2
Ex-smoker
3
Non-smoker - history unknown
4
Never smoked
9
Unknown
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Is / was the patient a smoker at the time of
delivery? (Mapping to MSDS in brackets)



Yes (1)
No (2, 3, 4)
Don’t know (9)
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7. Clinical Governance
Clinical governance is defined by Department of Health (DH) as:
“the system through which NHS organisations are accountable for continuously improving the
quality of their services and safeguarding high standards of care, by creating an environment
in which clinical excellence will flourish”148.
Governing and audit bodies can use the MSDS to monitor whether services are making year on year
improvements and data providers can use the data set to compare and contrast performance to help
drive service improvements.
8. Resource and Cost
Dependent on organisational processes, the resource implications for data providers required to
collect the data will vary. However, the most cost effective approach is likely to be one where data is
recorded once, at source and in an electronic system.
Data items initially captured on paper and subsequently transferred to an electronic system will
produce duplication in effort and time and an increased likelihood of data quality issues.
The current scope of the project does not include financial support for paper-based sites to procure,
install and provide adequate training to deploy electronic systems capable of delivering the standard
requirements. Organisations are encouraged to make provision to employ an interim solution and
progress the procurement of an IT system as early as possible.
Organisations which already employ an IT system are expected to upgrade and mature their current
systems to meet these standards.
9. Information Governance
Guidance for data and information sharing at both operational and secondary uses levels exists
nationally, for example The NHS Confidentiality Code of Practice (2003) and the Caldicott Report
(1997)149.
9.1. Consent and Opt Out
Explicit consent for the submissions of the MSDS is not required as a Privacy Impact Assessment
has instead been carried out in relation to the MCDS project. The Health and Social Care Information
Centre no longer needs to apply for Section 251 support where mandated to collect data and when
acting as data controller. This is set out in Sections 254 and 255 of the Health and Social Care Act
2012150. However, all data providers MUST still ensure compliance with the fair processing
requirement of the Data Protection Act 1998. To meet these requirements, data providers MUST
148
DH Clinical Governance definition
[http://webarchive.nationalarchives.gov.uk/+/www.dh.gov.uk/en/Publichealth/Patientsafety/Clinicalgovernance/index.htm]
149
Both documents available from
[http://www.dh.gov.uk/en/Managingyourorganisation/Informationpolicy/Patientconfidentialityandcaldicottguardians/DH_4084
181]
150
Health and Social Care Act 2012 [http://www.legislation.gov.uk/ukpga/2012/7/contents/enacted]
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make available information and guidance to mothers to inform them that their and their baby’s data
will be used for secondary uses purposes (such as service development analysis and national
statistical research).
Where a mother expresses the wish for their data not be used or disclosed, they should be informed
of their right to opt-out. There MUST be a mechanism for data providers to record a mother’s
decision to opt-out from such national data submissions and data providers MUST NOT include any
data relating to those pregnancies as part of their submission.
9.2. Subject access request and right to begin/cease data
processing
Subject Access Request under Section 7 and Cease Data Process under Section 10 of the Data
Protection Act 1998151 do not apply to this standard, as the HSCIC are now able to store patient
identifiable data under the Health and Social Care Act (2012). However, where the mother
expressively requests for the information to stop flowing, data providers MUST comply with the
request to meet the conditions of approval under Section 251 (of the NHS Act 2006).
9.3. Measures to Ensure Privacy of Patient Level Data
9.3.1. Identifiable Data Items
Using the Ethics and Confidentiality Committee’s (ECC) categorisation of identifiable data items152,
plus data items related to date & time of death, a number of MCDS data items are deemed
identifiable.
Within the central data warehouse, identifiable data items will either be pseudonymised153 or used for
derivation purposes only. Identifiable data items will not be made available via either the reporting or
the extraction tiers of the solution, except in reports and extracts to data providers.
151
Sections 7 and 10, DPA 1998 [http://www.legislation.gov.uk/ukpga/1998/29/contents]
152
ECC [http://www.nigb.nhs.uk/ecc/eccfrequently]
153
Pseudonymisation is a process where identifiable data items such as NHS Number are encrypted through a
standardised methodology so that data arriving from different Trusts and at different points in the care pathway can be
linked at a person level. Pseudonymised data items will not identify a person nor will the pseudonymisation key be
available to data users to allow them to reverse the encryption. The pseudonymisation key will be held securely by the Data
Controller (Health and Social Care Information Centre).
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The identifiable data items and their management are listed in the table below.
Identifiable data item
Management
NHS NUMBER (MOTHER)
This will be pseudonymised by the solution and is required
for the purpose of linking data segments for a patient
together, so that an end-to-end picture is built up for each
child and their mother’s pregnancy.
LOCAL PATIENT IDENTIFIER This will be pseudonymised by the solution and is required
(MOTHER)
for the purpose of linking data segments for a patient
together (where NHS Number is not provided), so that an
end-to-end picture is built up for each child and their
mother’s pregnancy.
PERSON BIRTH DATE
(MOTHER)
The Date of Birth will not be stored in the data warehouse.
The data item will be used to derive the age at which specific
events took place, e.g. age at referral, age at booking, to
enable demographic analysis and reporting.
POSTCODE OF USUAL
ADDRESS (MOTHER AT
BOOKING)
The full postcode will not be stored in the data warehouse.
The data item will be used to derive the lower level output
area in order to enable geographical analysis and reporting.
NHS NUMBER (BABY)
This will be pseudonymised by the solution and is required
for the purpose of linking data segments for a patient
together, so that an end-to-end picture is built up for each
child and their mother’s pregnancy.
LOCAL PATIENT IDENTIFIER This will be pseudonymised by the solution and is required
(BABY)
for the purpose of linking data segments for a patient
together (where NHS Number is not provided), so that an
end-to-end picture is built up for each child and their
mother’s pregnancy.
DATE TIME OF BIRTH
(BABY)
The Date of Birth will not be stored in the Central Data
Warehouse. The data item will be used to derive the age at
which specific events took place, e.g. age newborn physical
examination.
DATE TIME OF DEATH
(BABY)
The Date of Death will not be stored in the Central Data
Warehouse. The data item will be used to derive the age at
death to enable demographic analysis and reporting.
DATE TIME OF DEATH
(MOTHER)
The Date of Death will not be stored in the Central Data
Warehouse. The data item will be used to derive the age at
death to enable demographic analysis and reporting.
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9.3.2. Sensitive Data Items
The ECC’s Database Monitoring Sub Group (DMSG154) identified a small number of data items
deemed as sensitive. The MCDS developers have used this classification in order to identify
sensitive data items in the MSDS. These data items are listed below:
 Organisation Code (GMP Practice of Mother)
 Physical Disability Status Indicator (Mother at Booking)
 First Language English Indicator (Mother at Booking)
 Maternity Complicating Sexually Transmitted Infection Diagnosis (Mother at Booking)
 Offer Status (Screening Mother Syphilis)
 Blood Test Sample Date (Screening Mother Syphilis)
 Investigation Result (Screening Mother Syphilis)
 Offer Status (Screening Mother Human Immunodeficiency Virus)
 Blood Test Sample Date (Screening Mother Human Immunodeficiency Virus)
 Investigation Result (Screening Mother Human Immunodeficiency Virus)
 Maternity Sexually Transmitted Infection Diagnosis (Current Pregnancy)
 Start Date (Hospital Provider Spell Antenatal)
 Transfer Start Date Time (Neonatal Unit)
 Start Date (Hospital Provider Spell Postpartum)
Sensitive data items will only be reported at an aggregate level and will not be available for
extraction. Reporting on sensitive data items will be subject to the small numbers guidelines
available in the HES Analysis Guide (which has replaced the HES Protocol)155.
9.3.3. Sexual health data items
Under NHS Trusts and Primary Care Trusts (Sexually Transmitted Diseases) Direction 2000, data
items referring to the examination or treatment for sexual health cannot be disclosed for secondary
uses purposes.
The data submission framework has been designed such that data relating to the outcome of Sexual
Transmitted Infection (STI) screening and STI diagnosis, will flow anonymously. This approach will
affect the following data items:








Maternity Complicating Sexually Transmitted Infection Diagnosis (Mother at Booking)
Offer Status (Screening Mother Syphilis)
Blood Test Sample Date (Screening Mother Syphilis)
Investigation Result (Screening Mother Syphilis)
Offer Status (Screening Mother Human Immunodeficiency Virus)
Blood Test Sample Date (Screening Mother Human Immunodeficiency Virus)
Investigation Result (Screening Mother Human Immunodeficiency Virus)
Maternity Sexually Transmitted Infection Diagnosis (Current Pregnancy)
Since data will be submitted in anonymous form, data items cannot be linked to pseudonymised
patient records, so there is no risk of accidental disclosure.
154
DMsG has since been replaced by the Data Access Advisory Group (DAAG) [http://www.ic.nhs.uk/daag]
155
HES Access Controls (Analysis Guide and HES Protocol) for dissemination of data
[http://www.hesonline.nhs.uk/Ease/servlet/ContentServer?siteID=1937&categoryID=331]
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9.4. Data Retention
Data will be stored in the central data warehouse for the contracted life of the project in compliance
with the policy stated in ‘Records Management: NHS Code of Practice’ Part 2156.
On completion of the contracted life of the project, the data may be relocated to a successor system.
This transfer will also comply with laws, regulations and policies in force at that time.
9.5. Data Quality
As an output data set, the MSDS does not pose any requirement for the modelling and design of
local systems and, subsequently, local data quality measures. However, highlighted below, are
areas the data set developers recommend should be considered by data providers within their local
governance arrangements.
9.5.1. Corporate Data Quality Framework
Each organisation will have its own corporate framework for managing data quality in respect to data
collection, submission and publication. Such a framework is likely to involve a number of
components such as leadership and direction from a senior officer, organisational and departmental
data quality objectives, data quality audits and a performance management framework. It is
recommended that appropriate components of the corporate data quality framework include the
MSDS, so that data quality relating to the data set is at the heart of the organisation’s data quality
framework.
9.5.2. Data Quality Risks
At organisational, departmental and individual levels, risks related to data quality should be identified
and mitigated. Examples of risks, which could be considered, are:

Organisational - does the organisation have corporate policy and objectives for managing data?
Is there a senior officer with overall responsibility for data quality?

Team - are all relevant staff aware of the purpose and importance of collecting data for the
national data set? Are there sufficient resources available to continue data collection during staff
absences?

Individuals - do staff have sufficient time within their work routine to collect the data? Is there a
need for additional training so staff can possess appropriate skills to collect the data (especially
where systems are upgraded)?
9.5.3. Organisational and Departmental Objectives
In any organisation, resources will be deployed towards organisational and departmental objectives.
The organisation’s performance management framework will identify the extent to which objective are
met, and, where necessary, revised.
Where data set is used to monitor progress towards objectives, there will be greater emphasis on
collecting good quality data. It may be necessary to embed the data set subject area into the
organisation’s performance management framework (and therefore set local objectives) to ensure
data is collected in a reliable and timely manner.
156
Records Management NHS Code of Practice, Part 2, Annex D1
[http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4131747]
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The structure and internal processes of each data provider, as well as the departmental areas
covering the MSDS, will vary and, to a certain extent, depend on the priority given to IT and
informatics. Some organisations will have well developed processes and systems that, with
minimum effort, will accommodate the data set. Other organisations, for who processes and systems
are underdeveloped or in their infancy, may require significant changes. In such instances,
organisations may choose to plan the implementation of this Information Standard as a priority to
ensure sufficient resources are deployed for conformance.
The implementation of a new or re-engineered process may be more successful where organisations
use peer organisations to identify and replicate areas of good practice.
9.5.4. Timeliness
Although many data providers operate IT systems for data collection, hand-held notes are often still
the primary data collection tool. For clinical and management information purposes, data providers
may have to transcribe relevant data onto local IT systems, and in some cases this does not occur
until the midpoint or latter stages of the pregnancy.
The data set is split into a number of groups and each group must be submitted as part of the
reporting period where the event or episode took place. Groups submitted, relating to events or
episodes that took place during reporting periods where the submission window has closed will be
rejected by the central data warehouse. Therefore, data must be entered into local systems in a
timely fashion to enable the data providers to submit a complete and accurate data set in line with the
submission schedule.
Data providers may find it necessary to implement immediate improvement actions to ensure this
occurs, as failure to submit a complete and accurate data set may adversely affect clinical practice
standards and outcomes.
9.5.5. Local Data Validation
The validation, referred to in this document, the MSDS Technical Output Specification, the MSDS
Technical Guidance and the MSDS Reporting and Validation Specification, only relates to the
structure and validity of the submitted data. At the central data warehouse it will be impossible to
identify whether data is accurate and complete. For this, local data quality measures must be
implemented.
9.5.6. Documentation of Change
Where a new process for data capture is developed or changes made to existing processes,
documentation may assist in developing efficient processes. This can also provide continuity to the
data collection process during periods of staff absences and personnel changes.
9.6. Contractual Issues for Staff
There should be no conflicts or issues with regards to staff contracts under Agenda for Change and
the NHS Key Skills Framework.
9.7. Skill Mix Changes
With the implementation of the MSDS, there may be some implications on skill changes and training
for clinicians, administration personnel, informatics personnel and IT services.
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9.7.1. Clinicians
A local implementation strategy may require additional skills and training for clinicians in using new
functions and modules within an existing or new IT system.
9.7.2. Administration Personnel
A local implementation strategy may require additional skills and training for administration personnel
in using new functions and modules within an existing or new IT system. Additionally, administration
personnel may be responsible for transcribing data to a new IT system.
9.7.3. Informatics and IT Support Services
From an IT or Information Management Service perspective, skills may be required in;



developing and maintaining a local data warehouse
creating a submission file from a spectrum of local IT systems
creating uni or bi-directional interfaces between electronic systems
In order for a data provider to create and submit data submission files to the central data warehouse,
the informatics department should be closely involved in the project at all stages.
10. Reporting Guidance
Reports and extracts (in addition to pre-deadline validation reports and post-deadline extracts for
data providers) are available from the central data warehouse to authorised users.
In addition to standard reports, ad hoc requests for reports will be processed by the HSCIC. Reports
will also be published in the public domain, for example through the Department of Health, NHS
Commissioning Board, or HSCIC websites.
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11. Maintenance of the Information Standard
As this data set has been approved as a full operational standard, it will be subject to the national
data sets service maintenance function. The data set maintenance function will be responsible for
ensuring the information standard continues to reflect changes to priorities, policy, practice and/or
underlying classifications, thus remaining ‘fit of purpose’.
The scope of the maintenance process covers:




Management of change requests from users and stakeholders;
Specification of changes to the data set in response to changes in policy, practice, coding and
classifications;
The process for authorisation and approval of changes to data set items, including obtaining
ISB standard change approval
Undertaking periodic reviews of the data set including data items, definitions and data values
Dissemination of approved changes to data set users and stakeholders, once approved, will be
issued in the form of an Information Standards Notice (ISN) by the ISB.
Where stakeholders wish to recommend changes to the MSDS, a completed Data Set Change
Request Template outlining any proposed changes to the data set should be requested and
submitted to the HSCIC enquiries@ic.nhs.uk (please include 'FAO Maternity Services Secondary
Uses Data Set’ in the subject line).
Each change request should be supported by a valid business requirement i.e. what change is
needed, justification (i.e. why is it needed) and also any associated timescales.
Any change requests will be considered and agreed by the sponsor prior to submission to the NHS
Information Standards Board (ISB) for formal approval and the publication of an ISN. The ISN will
inform the NHS and systems suppliers of the changes and timescales.
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