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.