Introduction

This quality standard covers the management of twin and triplet pregnancies in the antenatal period. For more information, see the multiple pregnancy scope.

Why this quality standard is needed

The incidence of multiple births has risen in the last 30 years. In 1980, 10 women per 1000 had multiple births in England and Wales compared with 16 per 1000 in 2011. This increase in multiple births is due mainly to the use of assisted reproduction techniques, including in vitro fertilisation (IVF). Older women are more likely to have a multiple pregnancy and, because the average age at which women give birth is rising, this is also a contributory factor. Multiple births currently account for 3% of live births.

Multiple pregnancy is associated with higher risks for the mother and babies. Maternal mortality associated with multiple births is 2.5 times that for singleton births. The risk of preterm birth is also considerably higher in multiple pregnancies than in singleton pregnancies, occurring in at least 50% of twin pregnancies. The significantly higher preterm delivery rates in twin and triplet pregnancies result in increased demand for specialist neonatal resources.

Risks to fetuses depend partly on the chorionicity (number of chorionic [outer] membranes) and amnionicity (number of amnion [inner] membranes) of the pregnancy. Feto-fetal transfusion syndrome, a condition associated with a shared placenta, can occur in monochorionic pregnancies and accounts for about 20% of stillbirths in multiple pregnancies. Additional risks to the fetuses include intrauterine growth restriction and congenital abnormalities.

How this quality standard supports delivery of outcome frameworks

NICE quality standards are a concise set of prioritised statements designed to drive measureable quality improvements within a particular area of health or care. They are derived from high-quality guidance, such as that from NICE or other sources accredited by NICE. This quality standard, in conjunction with the guidance on which it is based, should contribute to the improvements outlined in the following 2 outcomes frameworks published by the Department of Health:

Tables 1 and 2 show the outcomes, overarching indicators and improvement areas from the frameworks that the quality standard could contribute to achieving.

Table 1 NHS Outcomes Framework 2013/14

Domain

Overarching indicators and improvement areas

1 Preventing people from dying prematurely

Improvement areas

Reducing deaths in babies and young children

1.6i Infant mortality*

1.6ii Neonatal mortality and stillbirths

4 Ensuring that people have a positive experience of care

Improvement areas

Improving women and their families' experience of maternity services

4.5 Women's experience of maternity services

5 Treating and caring for people in a safe environment and protecting them from avoidable harm

Improvement areas

Improving the safety of maternity services

5.5 Admission of full-term babies to neonatal care

Alignment across the health and social care system

* Indicator shared with Public Health Outcomes Framework (PHOF)

Table 2 Public health outcomes framework for England, 2013–2016

Domain

Objectives and indicators

4 Healthcare, public health and preventing premature mortality

Objective

Reduced numbers of people living with preventable ill health and people dying prematurely, while reducing the gap between communities

Indicators

4.1 Infant mortality*

Alignment across the health and social care system

* Indicator shared with NHS Outcomes Framework (NHSOF)

Coordinated services

The quality standard for multiple pregnancy specifies that services should be commissioned from and coordinated across all relevant agencies encompassing the whole multiple pregnancy care pathway. A person-centred, integrated approach to providing services is fundamental to delivering high-quality care to women with a multiple pregnancy.

The Health and Social Care Act 2012 sets out a clear expectation that the care system should consider NICE quality standards in planning and delivering services, as part of a general duty to secure continuous improvement in quality. Commissioners and providers of health and social care should refer to the library of NICE quality standards when designing high-quality services. Other quality standards that should also be considered when choosing, commissioning or providing a high-quality multiple pregnancy service are listed in related quality standards.

Training and competencies

The quality standard should be read in the context of national and local guidelines on training and competencies. All healthcare practitioners involved in assessing, caring for and treating women with a multiple pregnancy should have sufficient and appropriate training and competencies to deliver the actions and interventions described in the quality standard.