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A global reference for CS at health facilities? Yes, but there is work to do

The caesarean section (CS) debate continues relentlessly and remains focused on trying to determine the ideal overall rate. This article by Souza et al. looks at whether it is possible to generate a global reference for CS at health facilities. Traditionally, more emphasis has been placed on standardising processes of care (guidelines) rather than standardising analysis of outcomes (perinatal audit) as part of evidencebased medicine. Transforming crude information into useful knowledge has long been required in perinatal audit. An effective perinatal classification requires a structure that is prospective, robust and simple. It must have the ability and be used to incorporate epidemiological variables in addition to other important perinatal events, outcomes and processes to generate a useful reference for CS. Quality of care is ultimately related to all outcomes taken together, not just CS, and it is all outcomes together that will guide practice (Audit and standards of intrapartum care; Robson. Munro Kerr’s Operative Obstetrics. Chapter 3, 12th Edn. Edinburgh: Elsevier, 2014). The principles of perinatal audit are that overall rates of any event or outcome are meaningless unless there is some sort of stratification. Also, no perinatal event or outcome should be interpreted on their own without considering the impact on other relevant outcomes. Comparing all outcomes between different units and relating them to practice enables learning to take place, possibly leading to change in practice. This is the philosophy of The Ten Group Classification System (TGCS) (Robson. Best Pract Res Clin Obstet Gynaecol 2013;27:297–308). Souza et al. in their article have developed and propose a caesarean section reference model using the TGCS as its basis. There are four versions of their C-model, each version adding more sophistication depending on what additional clinical information was available and used. Importantly though, stillbirth rates have not been used and there is limited information on maternal and neonatal outcome. These are not flaws of the model, rather it should be interpreted as a requirement to improve our perinatal data collection. A reference model for CS will only work if the raw data are available, validated and interpreted with other maternal and neonatal outcomes. This, sadly, is not possible inmost countries currently. With effective standardisation and classification (TGCS) as a basis for a reference model there are three reasons for differences in either sizes of groups or events and outcomes within groups. First, data quality (either in definitions or in the accuracy of data collection); secondly, significant differences in epidemiological variables and casemix; and thirdly, practice variation. The first two are prerequisites to considerations of practice variation. The responsibility for clinicians currently is to ensure good perinatal data collectionandusetheTGCStointerpret the results. If a global reference for CS is going to be truly beneficial we need all delivery units to contribute, and this should include both maternal and neonatal,shorttermandlong-termdata. There is little doubt that reference models (good quality, classified and adjusted perinatal audit) continually refined, will be used as the guide to the quality of perinatal care provided in the future. Furthermore, the most valuable reference models may be in individual groups of women rather than in an overall population. This article has started that process and the authors should be commended for that.