31 Observer agreement of aCTG assessments Other studies on the reliability of the overall classification of CTG patterns among healthcare professionals in obstetrician-led care showed a lower rate of observer agreement.12, 13 Ayres-de-Campos et al. found a proportion of agreement of 0.62 for normal traces, 0.42 for suspicious traces, and 0.25 for pathological traces.12 This difference in agreement levels compared to our findings may partly be related to the fact that they expressed the proportion of agreement for ante- and intrapartum CTGs together and not specifically for antepartum CTG traces as in our study. In our study, the participants assessed a sample of aCTGs selected from a population of healthy women with a specific aCTG indication, which includes a larger number of reassuring traces and thus yields a higher level of agreement.25 Previous studies showed variable results for the assessment of the various components of the aCTG: good to excellent interobserver agreement in aCTG assessment was found for baseline heart frequency, accelerations, and contractions, in contrast to other aCTG components such as the variability and decelerations.9, 11 In our study, for the various aCTG components, the proportions of agreement for interobserver agreement varied from 0.64 (presence of contractions) to 0.98 (baseline heart frequency). We suggest two main reasons for these differences. First, in our study the aCTG component deceleration was dichotomized into present or absent, instead of classifying deceleration as early, variable, or late, as defined in FIGO guideline. Second, exposure to aCTGs in clinical practice has increased in the past decade, potentially improving professionals’ assessment of aCTGs. Other studies showed that both clinical midwives and residents had better agreement than obstetricians.25, 26 We also found that the level of interobserver agreement in the classification of aCTGs within the professional group of residents was higher than within the group of obstetricians. Di Lieto et al. assessed the agreement in aCTG interpretation between experienced and inexperienced assessors. They found no differences between experienced and inexperienced professionals.14 This is in line with our results, showing comparable interobserver agreement levels between different professionals (e.g., primary care midwives and obstetricians) for the classification of aCTGs, despite differences in years of experience. In line with the literature,13 we detected a slightly higher level of intraobserver agreement than interobserver agreement for the classification of aCTGs. This observation shows consistency in the assessment of aCTGs by all maternity care professionals. It should be noted that high levels of agreement do not necessarily mean that the aCTGs have been assessed correctly. It indicates whether different professional groups provided the same assessment with a comparable level of error when classifying aCTGs. 2
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