title: 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.
abstract: 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.
  
  
  METHODS
  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) non-progressive 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.
authors.affiliation: GROW- School for Oncology and Developmental Biology, Department of Obstetrics and Gynaecology, Maastricht University Medical Center, P.O. Box 5800, 6202 AZ Maastricht, The Netherlands.
authors.forename: Sonja
authors.initials: S
authors.lastname: Melman
authors.affiliation: GROW- School for Oncology and Developmental Biology, Department of Obstetrics and Gynaecology, Maastricht University Medical Center, P.O. Box 5800, 6202 AZ Maastricht, The Netherlands.
authors.forename: Ellen C N
authors.initials: EC
authors.lastname: Schoorel
authors.affiliation: Department of Obstetrics and Gynaecology, Rijnstate Hospital, P.O. Box 9555, 6800 TA Arnhem, The Netherlands.
authors.forename: Karin
authors.initials: K
authors.lastname: de Boer
authors.affiliation: Midwives Zaltbommel en Maasdriel, Hogeweg 141, 5301 LL Zaltbommel, The Netherlands.
authors.forename: Henriëtte
authors.initials: H
authors.lastname: Burggraaf
authors.affiliation: Department of Obstetrics and Gynaecology, University Medical Hospital Utrecht, P.O. Box 85090, 3508 AB Utrecht, The Netherlands.
authors.forename: Jan B
authors.initials: JB
authors.lastname: Derks
authors.affiliation: Department of Obstetrics, Leiden University Medical Center, P.O. Box 9600, 2300 RC Leiden, The Netherlands.
authors.forename: Det
authors.initials: D
authors.lastname: van Dijk
authors.affiliation: Department of Obstetrics and Gynaecology, Radboud University Nijmegen Medical Center, P.O. Box 9101, 6500 HB Nijmegen, The Netherlands.
authors.forename: Jeroen
authors.initials: J
authors.lastname: van Dillen
authors.affiliation: Department of Clinical Epidemiology and Medical Technology Assessment (KEMTA), Maastricht University Medical Center, P.O. Box 5800, 6202 AZ Maastricht, The Netherlands.
authors.forename: Carmen D
authors.initials: CD
authors.lastname: Dirksen
authors.affiliation: Department of Obstetrics and Gynaecology, Erasmus Medical Center, P.O. Box 2060, 3000 CB Rotterdam, The Netherlands.
authors.forename: Johannes J
authors.initials: JJ
authors.lastname: Duvekot
authors.affiliation: Department of Obstetrics and Gynaecology, University Medical Hospital Utrecht, P.O. Box 85090, 3508 AB Utrecht, The Netherlands.
authors.forename: Arie
authors.initials: A
authors.lastname: Franx
authors.affiliation: Department of Obstetrics and Gynaecology, Catharina-Hospital, P.O. Box 1350, 5602 ZA Eindhoven, The Netherlands.
authors.forename: Tom H M
authors.initials: TH
authors.lastname: Hasaart
authors.affiliation: Department of Obstetrics and Gynaecology, Gelre Hospital, P.O. Box 9014, 7300 DS Apeldoorn, the Netherlands.
authors.forename: Anjoke J M
authors.initials: AJ
authors.lastname: Huisjes
authors.affiliation: Royal Dutch Organization of Midwives (KNOV), Mercatorlaan 1200, 3528 BL Utrecht, The Netherlands.
authors.forename: Diny
authors.initials: D
authors.lastname: Kolkman
authors.affiliation: Department of Epidemiology, Caphri School for Public Health and Primary Care, Maastricht University Medical Center, Maastricht, The Netherlands.
authors.forename: Sander
authors.initials: S
authors.lastname: van Kuijk
authors.affiliation: Department of Obstetrics and Gynaecology, University Medical Hospital Utrecht, P.O. Box 85090, 3508 AB Utrecht, The Netherlands.
authors.forename: Anneke
authors.initials: A
authors.lastname: Kwee
authors.affiliation: Department of Obstetrics and Gynaecology, Academic Medical Center, University of Amsterdam, P.O. Box 22660, 1100 DD Amsterdam, The Netherlands.
authors.forename: Ben W
authors.initials: BW
authors.lastname: Mol
authors.affiliation: Department of Obstetrics and Gynaecology, Onze Lieve Vrouwe Gasthuis, Amsterdam, Oosterpark 9, 1091 AC Amsterdam, The Netherlands.
authors.forename: Mariëlle G
authors.initials: MG
authors.lastname: van Pampus
authors.affiliation: Royal Dutch Organization of Midwives (KNOV), Mercatorlaan 1200, 3528 BL Utrecht, The Netherlands.
authors.forename: Alieke
authors.initials: A
authors.lastname: de Roon-Immerzeel
authors.affiliation: Department of Obstetrics, Leiden University Medical Center, P.O. Box 9600, 2300 RC Leiden, The Netherlands.
authors.forename: Jos J M
authors.initials: JJ
authors.lastname: van Roosmalen
authors.affiliation: Department of Obstetrics and Gynaecology, Atrium Medical Center Parkstad, P.O. Box 4446, 6401 CX Heerlen, The Netherlands.
authors.forename: Frans J M E
authors.initials: FJ
authors.lastname: Roumen
authors.affiliation: Department of Obstetrics and Gynaecology, Ruwaard van Putten Hospital, P.O. Box 777, 3200 GA Spijkenisse, The Netherlands.
authors.forename: Ellen
authors.initials: E
authors.lastname: Smid-Koopman
authors.affiliation: Department of Epidemiology, Caphri School for Public Health and Primary Care, Maastricht University Medical Center, Maastricht, The Netherlands.
authors.forename: Luc
authors.initials: L
authors.lastname: Smits
authors.affiliation: Department of Obstetrics and Gynaecology, Jeroen Bosch Hospital, P.O. Box 90153, 5200 ME 's-Hertogenbosch, The Netherlands.
authors.forename: Wilbert A
authors.initials: WA
authors.lastname: Spaans
authors.affiliation: Department of Obstetrics and Gynaecology, Tergooi Hospital Blaricum, P.O. Box 10016, 1201 DA Hilversum, The Netherlands.
authors.forename: Harry
authors.initials: H
authors.lastname: Visser
authors.affiliation: Department of Obstetrics and Gynaecology, Bronovo Hospital, P.O. Box 96900, 2509 JH Den Haag, The Netherlands.
authors.forename: Wim J
authors.initials: WJ
authors.lastname: van Wijngaarden
authors.affiliation: GROW- School for Oncology and Developmental Biology, Department of Obstetrics and Gynaecology, Maastricht University Medical Center, P.O. Box 5800, 6202 AZ Maastricht, The Netherlands.
authors.forename: Christine
authors.initials: C
authors.lastname: Willekes
authors.affiliation: Department of Obstetrics and Gynaecology, VU University Medical Center Amsterdam, P.O. Box 7057, 1007 MB Amsterdam, The Netherlands.
authors.forename: Maurice G A J
authors.initials: MG
authors.lastname: Wouters
authors.affiliation: GROW- School for Oncology and Developmental Biology, Department of Obstetrics and Gynaecology, Maastricht University Medical Center, P.O. Box 5800, 6202 AZ Maastricht, The Netherlands.
authors.forename: Jan G
authors.initials: JG
authors.lastname: Nijhuis
authors.affiliation: Scientific Institute for Quality of Healthcare (IQ healthcare), Radboud University Medical Center Nijmegen, P.O. Box 9101, 6500 HB Nijmegen, The Netherlands.
authors.forename: Rosella P M G
authors.initials: RP
authors.lastname: Hermens
authors.affiliation: GROW- School for Oncology and Developmental Biology, Department of Obstetrics and Gynaecology, Maastricht University Medical Center, P.O. Box 5800, 6202 AZ Maastricht, The Netherlands.
authors.forename: Hubertina C J
authors.initials: HC
authors.lastname: Scheepers
mesh_terms: D002585:Cesarean Section / Q000592:standards* / Q000706:statistics & numerical data; D003697:Delphi Technique; D005260:Female; D019983:Guideline Adherence / Q000592:standards*; D017408:Guidelines as Topic; D006801:Humans; D009426:Netherlands