Development and measurement of guidelines-based quality indicators of caesarean section care in the Netherlands: A RAND-modified delphi procedure and retrospective medical chart review

Sonja Melman, Ellen C.N. Schoorel, Karin De Boer, Henriëtte Burggraaf, Jan B. Derks, Det Van Dijk, Jeroen Van Dillen, Carmen D. Dirksen, Johannes J. Duvekot, Arie Franx, Tom H.M. Hasaart, Anjoke J.M. Huisjes, Diny Kolkman, Sander Van Kuijk, Anneke Kwee, Ben W. Mol, Mariëlle G. Van Pampus, Alieke De Roon-Immerzeel, Jos J.M. Van Roosmalen, Frans J.M.E. RoumenEllen Smid-Koopman, Luc Smits, Wilbert A. Spaans, Harry Visser, Wim J. Van Wijngaarden, Christine Willekes, Maurice G.A.J. Wouters, Jan G. Nijhuis, Rosella P.M.G. Hermens, Hubertina C.J. Scheepers

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12 Citations (Scopus)


Background: There is an ongoing discussion on the rising CS rate worldwide. Suboptimal guideline adherence may be an important contributor to this rise. Before improvement of care can be established, optimal CS care in different settings has to be defined. This study aimed to develop and measure quality indicators to determine guideline adherence and identify target groups for improvement of care with direct effect on caesarean section (CS) rates. Method: Eighteen obstetricians and midwives participated in an expert panel for systematic CS quality indicator development according to the RAND-modified Delphi method. A multi-center study was performed and medical charts of 1024 women with a CS and a stratified and weighted randomly selected group of 1036 women with a vaginal delivery were analysed. Quality indicator frequency and adherence were scored in 2060 women with a CS or vaginal delivery. Results: The expert panel developed 16 indicators on planned CS and 11 indicators on unplanned CS. Indicator adherence was calculated, defined as the number of women in a specific obstetrical situation in which care was performed as recommended in both planned and unplanned CS settings. The most frequently occurring obstetrical situations with low indicator adherence were: 1) suspected fetal distress (frequency 17%, adherence 46%), 2) nonprogressive labour (frequency 12%, CS performed too early in over 75%), 3) continuous support during labour (frequency 88%, adherence 37%) and 4) previous CS (frequency 12%), with adequate counselling in 15%. Conclusions: We identified four concrete target groups for improvement of obstetrical care, which can be used as a starting point to reduce CS rates worldwide.

Original languageEnglish
Article numbere0145771
JournalPloS one
Issue number1
Publication statusPublished or Issued - 1 Jan 2016
Externally publishedYes

ASJC Scopus subject areas

  • General

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