Strengths and limitations
A strength of the study is the prospective and national design, and uniform data collection using the Norwegian Medical Birth Registry. Standard obstetric practice was based on the Norwegian national guidelines. 24 After education and training, the reproducibility of the ICSCS was tested for midwifes and doctors before data collection was started; all achieved good or very good levels of agreement. In contrast to other indication systems, all births were first classified according to the TGCS 7 and then subsequently classified using the ICSCS.
A fundamental measure of quality care is knowing your results, including the ability to interpret them.25 We agree with the authors of the system that this enables a much better clinical interpretation of the CS rate as the incidence and risk benefit ratio of the indications varies according to the different groups. For example staff refraining from using oxytocin in women with a previous CS was reflected in a higher incidence of dystocia-inefficient uterine action-no oxytocin in women with a previous CS (Group 5) compared to the remaining groups (1-4).
Non-participation of some units (18% of the birth population), some missing project forms and population differences between participating and non-participating units are relative weaknesses but did not affect the purpose of the study.
There was a strong consensus within the project group about the benefits of the ICSCS within the TGCS system as part of a recommended audit and feedback. 26 However without a suitable electronic patient record (EPR) and perinatal database implementation on a routine basis nationally was not felt to be possible at the present time. Unfortunately the process of introducing changes into different EPRs (there are currently 3 maternity EPRs in Norway) and subsequent approval by the Medical Birth Registry are challenging and time-consuming. During the training initially it was difficult for some participants to grasp the concept that this classification system is completely independent and applicable irrespective of the guidelines used in the management of labour. The study did reveal though that, despite national guidelines, the CS rate according to the TGCS and the high level classification system used in this study did produce different results between participating units (data not shown). This initiated a discussion about relevant differences in local obstetric practice based on an objective and reproducible classification of CS (Suppl. 2). Performed either as a comparison between units or as a longitudinal assessment at one unit it may highlight areas for improvement in perinatal care or confirmation of appropriate care. For example, the prevalence of the fetal indication (no oxytocin) group should be relatively similar within the same groups of women (based on the TGCS and similar epidemiological case mix) and identical guidelines for fetal monitoring. Existing differences should then be related to other perinatal outcome measures and could reveal either an over- or under-use of CS for fetal indication. This type of quality assessment as a result of using the classification was positively embraced by all participants.