A systematic review of the Robson classification for caesarean section: what works, doesn't work and how to improve it

Examining the role and relevance of the critical analysis and comparison of cesarean section rates in a changing world

Cesarean section (CS) is one of the most commonly performed surgical operations in the world and has resulted in improved maternal and neonatal morbidity and mortality rates internationally. However, concerns have been raised regarding the ever increasing CS rates to what has been described as 'epidemic' proportions. Global CS rates have increased from 6.7% in 1990 to 19.1% in 2014. However, there is a vast variation in the CS rates between countries with CS rates of 44.3% reported across Latin America & the Caribbean and CS rates as low as 4.1% in central and West Africa. There is much controversy regarding the optimal figure for CS in a population. The optimal CS rates for a population have been recommend in various studies, ranging from 10% to 19%, above which no reported improvement in maternal and neonatal mortality rates is observed. This review examines the evolution of the changing indications for CS and increasing CS rates in a world where family sizes are reducing and maternal age at first pregnancy is increasing. Efforts must be made to agree on an appropriate classification system whereby CS rates can be compared accurately between units and countries as a useful tool to audit and monitor our practice. Obstetricians should consider the indications for each CS performed, be conscious of the CS rate in our own countries and institutions and most importantly, be cognizant of how the CS rate impacts the maternal and perinatal morbidity and mortality rates and adjust our practice accordingly, to minimize harm.

Analysis of cesarean section rates using Robson ten group classification system in a tertiary teaching hospital, Addis Ababa, Ethiopia: a cross-sectional study

BACKGROUND

Cesarean section (CS) is an important indicator of access to, and quality of maternal health services. The World Health Organization recommends the Robson ten group classification system as a global standard for assessing, monitoring and comparing CS rates at all levels. This study aimed to assess the rate of CS and perform an analysis based on Robson classification system.

METHODS

A facility-based cross-sectional study was conducted at a tertiary hospital in Addis Ababa, Ethiopia. Data were collected from medical charts of all women who delivered from January-June 2018. The overall CS rate was calculated then women were categorized into one of the ten Robson groups. Relative size of each group, contribution of each group to the overall CS rate, and CS rate within each group were calculated.

RESULTS

A total of 4,200 deliveries were analyzed. Of these 1,459 (34.7%) were CS. The largest contributors to the overall CS rate were Group 10 (19.1%), Group 2 (18.3%), Group 5 (17.1%), and Group 4 (15.8%). There was also a high rate of pre-labor CS in Group 2, Group 4, and Group 10.

CONCLUSION

Through implementation of the Robson ten group classification system, we identified the contribution of each group to the overall CS rate as well as the CS rate within each group. Group 10 was the leading contributor to the overall CS rate. This study also revealed a high rate of CS among low-risk groups. These target groups require more in-depth analysis to identify possible modifiable factors and to apply specific interventions to reduce the CS rate. Evaluation of existing management protocols and further studies into indications of CS and outcomes are needed to design tailored strategies and improve outcomes.

The Robson classification for caesarean section-A proposed method based on routinely collected health data

BACKGROUND

With an increasing rate of caesarean sections as well as rising numbers of multiple pregnancies, valid classifications for benchmarking are needed. The Robson classification provides a method to group cases with caesarean section in order to assess differences in outcome across regions and sites. In this study we set up a novel method of classification by using routinely collected health data. We hypothesize i that routinely collected health data can be used to apply complex medical classifications and ii that the Robson classification is capable of classifying mothers and their corresponding newborn into meaningful groups with regard to outcome.

METHODS AND FINDINGS

The study was conducted at the coding department and the department of obstetrics and gynecology Inselspital, University Hospital of Bern, Switzerland. The study population contained inpatient cases from 2014 until 2017. Administrative and health data were extracted from the Data Warehouse. Cases were classified by a Structured Query Language code according to the Robson criteria using data from the administrative system, the electronic health record and from the laboratory system. An automated query to classify the cases according to Robson could be implemented and successfully validated. A linkage of the mother's class to the corresponding newborn could be established. The distribution of clinical indicators was described. It could be shown that the Robson classes are associated to outcome parameters and case related costs.

CONCLUSIONS

With this study it could be demonstrated, that a complex query on routinely collected health data would serve for medical classification and monitoring of quality and outcome. Risk-stratification might be conducted using this data set and should be the next step in order to evaluate the Robson criteria and outcome. This study will enhance the discussion to adopt an automated classification on routinely collected health data for quality assurance purposes.

Caesarean section rates analysed using Robson's 10-Group Classification System: a cross-sectional study at a tertiary hospital in Ethiopia

OBJECTIVE

The aim of this study was to assess the caesarean section (CS) rates using Robson's 10-Group Classification System among women who gave birth at Hawassa University Referral Hospital in southern Ethiopia.

DESIGN

Cross-sectional study design to determine CS rate using Robson's 10-Group Classification System.

SETTING

Hawassa University Referral Hospital in south Ethiopia.

PARTICIPANTS

4004 women who gave birth in Hawassa University Referral Hospital from June 2018 to June 2019.

RESULTS

The 4004 women gave birth to 4165 babies. The overall CS rate was 32.8% (95% CI: 31.4%-34.3%). The major contributors to the overall CS rates were: Robson group 1 (nulliparous women with singleton pregnancy at term in spontaneous labour) 22.9%; group 5 (multiparous women with at least one previous CS) 21.4% and group 3 (multiparous women without previous CS, with singleton pregnancy in spontaneous labour) 17.3%. The most commonly reported indications for CS were 'fetal compromise' (35.3%) followed by previous CS (20.3%) and obstructed labour (10.7%).

CONCLUSION

A high proportion of women giving birth at this hospital were given a CS, and many of them were in a low-risk group. Few had trial of labour. More active use of partogram, improving fetal heartbeat-monitoring system, implementing midwife-led care, involving a companion during labour and auditing the appropriateness of CS indications may help to reduce the CS rate.

Can pre-eclampsia explain higher cesarean rates in the different groups of Robson's classification?

OBJECTIVE

To evaluate the impact of pre-eclampsia on cesarean delivery by using the Robson classification.

METHODS

A retrospective cross-sectional study including all women who delivered in a referral maternity hospital in southeast Brazil from January 2017 to February 2018. Women were classified into 1 of 10 Robson groups and then further subdivided into pre-eclampsia (PE) and non-PE (NPE) groups. Frequency of cesarean was determined for each group and compared by using χ² and prevalence ratio.

RESULTS

Overall, 3102 women were included, of whom 1578 (50.9%) delivered by cesarean. Classification in Robson group 5 was the most frequent among all women (n=727, 23.4%). In the PE group (n=258, 8.3%), group 10 was the most frequent classification (n=120, 46.5%); in NPE, Robson group 5 was the most frequency (n=682, 24.0%). Pre-eclampsia was associated with a higher occurrence of cesarean (77.5% vs 48.4%; prevalence ratio, 2.29; 95% confidence interval, 1.82-2.82), owing to higher rates in Robson groups 1, 5, and 10.

CONCLUSION

Pre-eclampsia was associated with a higher occurrence of cesarean delivery in some Robson groups. Robson classification may be used to evaluate the impact of specific conditions at a facility level to help plan future interventions to optimize the use of cesarean.

Impact of clinical audits on cesarean section rate in a Spanish hospital: Analysis of 6 year data according to the Robson classification

OBJECTIVES

The aim of this study is to analyze the impact of the introduction of an internal clinical audit on the cesarean section (CS) rate, evaluated according to the Robson Ten Group Classification System (TGCS), and to identify the main contributors to the overall CS rate in order to plan further interventions.

STUDY DESIGN

In 2014, an internal clinic audit committee was established in our center. Modifications of clinical management protocols were also implemented. A retrospective review of clinical records was conducted and pre-audit (2011-2014) results were compared against audit (2015-2018) results. Patients were clustered according to the Robson TGCS and the analyzed outcomes were CS rate and maternal and neonatal results.

RESULTS

Between January 2011 and December 2018, 12,766 women gave birth at our institution among which 2,281 CS were analyzed. After the establishment of the clinical audit, the overall CS rate decreased from 20.27% to 14.82 % (p < 0.01). The major contribution to the overall CS rate in both periods were made by Group 2a (nulliparous with a single cephalic pregnancy at term who underwent labor induction: 4.86 % of all cases), followed by Group 5 (patients with a previous C-section: 3.26 %) and Group 1 (nulliparous with a single cephalic pregnancy at term with spontaneous labor: 2.39 %), representing 59.6 % of all CS. The group that showed the greatest reduction to the overall Cs rate was Group 2 (5.77 % vs 3.96 %, OR 1.48 (p < 0.01). No differences in perinatal and maternal results were found between preaudit and audit group.

CONCLUSION

Audit, feedback, and modification of clinical management protocols may be effective in changing clinical practice and reducing CS rates without worsening maternal and neonatal morbimortality. Robson TGCS allowed us to identify which groups had the greatest impact on CS rate in order to establish new strategies that may lead us to optimize the use of this intervention. It seems that efforts to reduce the overall CS rate should be directed on increasing vaginal birth after CS and reducing CS rates in nulliparous women with single cephalic full-term pregnancy.

Patient anxiety of verticalization on day 0 after a Cesarean section

Purpose

The ERAS protocol recommends fast mobilization of a patient along with providing psychological comfort; however, early verticalization can generate mental discomfort. In the post-operative period after Caesarean section (CC), a patient may experience pain, anxiety and negative affect. The main aim of the study was to investigate levels of patient anxiety concerning verticalization on day 0 after CC using. Also, the dependence between anxiety of verticalization and the following: pain, anxiety as a permanent disposition, resistance to pain, negative and positive emotions, and positive orientation was described.

Methods

The study included 150 women on day 0 after their CC. The measurement of anxiety concerning verticalization, pain, and also negative and positive emotions was conducted twice. During the first measurement, variables such as anxiety levels as a constant disposition, level of pain resistance and positive orientation were also monitored.

Results

Patients upon arrival at the post-operative room declared a higher level of anxiety of verticalization (p < 0.05) (Median = 4; IQR = 5) when compared to 6 h after surgery (Median = 3; IQR = 4). A weak correlation of anxiety and pain was noted (r = 0.264; p < 0.01) in the second measurement. In both measurements, negative emotions and pain resistance proved to be the strongest variables explaining anxiety concerning verticalization.

Conclusions

Low levels of pain experienced by a patient after CC do not explain the variance in anxiety of verticalization. The use of the Numerical Rating Scale (NRS) of anxiety allows care givers to gain patients' psychological perspective in different moments after CC.

Perinatal outcomes from preterm and early term births in a multicenter cohort of low risk nulliparous women

Preterm birth is the major contributor for neonatal and under-five years mortality rates and also accounts for a short- and long-term adverse consequences up to adulthood. Perinatal outcomes may vary according to lots of factors as preterm subtype, late prematurity, which account for the vast majority of cases, country and population characteristics. An under-recognition of the perinatal outcomes and its associated factors might have underpowered strategies to provide adequate care and prevent its occurrence. We aim to estimate the frequency of maternal and perinatal outcomes in women with different categories of preterm and term births, factors associated with poorer perinatal outcomes and related management interventions. A multicentre prospective cohort in five maternities in Brazil between 2015 and 2018. Nulliparous low-risk women with singletons were included. Comprehensive data were collected during three antenatal visits (at 19-21weeks, 27-29 weeks and 37-39 weeks). Maternal and perinatal outcomes were also collected according to maternal and neonatal medical records. Women who had spontaneous (sPTB) and provider-initiated (pi-PTB) preterm birth were compared to those who had term birth. Also, late preterm birth (after 34 weeks), and early term (37-38 weeks) were compared to full term birth (39-40 weeks). Bivariate analysis estimated risk ratios for maternal and adverse outcomes. Finally, a multivariate analysis was conducted to address factors independently associated with any adverse perinatal outcome (APO). In total, 1,165 women had outcome data available, from which 6.7% had sPTB, 4.0% had pi-PTB and 89.3% had a term birth. sPTB and pi-PTb were associated with poorer perinatal outcomes, as well as late sPTB, late pi-PTB and early term neonates. pi-PTB (RRadj 8.12, 95% CI [2.54-25.93], p-value 0.007), maternal weight gain between 20 and 27 weeks Collapse

Key Words

• medical research
• epidemiology

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MESH Headings

• Adult
• Brazil/epidemiology
• Female
• Humans
• Infant, Low Birth Weight/growth & development
• Infant, Newborn
• Longitudinal Studies
• Parity
• Pregnancy
• Premature Birth/epidemiology
• Prognosis
• Prospective Studies
• Risk Factors
• Term Birth/physiology
• Young Adult

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Affiliation(s)

Renato T Souza Department of Obstetrics and Gynaecology, University of Campinas (UNICAMP) School of Medical Sciences, Campinas, SP, Brazil
Maria L Costa Department of Obstetrics and Gynaecology, University of Campinas (UNICAMP) School of Medical Sciences, Campinas, SP, Brazil
Jussara Mayrink Department of Obstetrics and Gynaecology, University of Campinas (UNICAMP) School of Medical Sciences, Campinas, SP, Brazil
Francisco E Feitosa MEAC - School Maternity of the Federal University of Ceará, in Fortaleza, CE, Brazil
Edilberto A Rocha Filho Department of Maternal and Child Health, Maternity of Clinic Hospital, Federal University of Pernambuco, in Recife, PE, Brazil
Débora F Leite Department of Obstetrics and Gynaecology, University of Campinas (UNICAMP) School of Medical Sciences, Campinas, SP, Brazil Department of Maternal and Child Health, Maternity of Clinic Hospital, Federal University of Pernambuco, in Recife, PE, Brazil
Janete Vettorazzi Department of Obstetrics and Gynaecology, Maternity of the Clinic Hospital, Federal University of RS, Porto Alegre, RS, Brazil
Iracema M Calderon Department of Obstetrics and Gynaecology, Botucatu Medical School, Unesp, Botucatu, SP, Brazil
Maria H Sousa Statistics Unit, Jundiai School of Medicine, Jundiaí, SP, Brazil
Renato Passini Department of Obstetrics and Gynaecology, University of Campinas (UNICAMP) School of Medical Sciences, Campinas, SP, Brazil
Philip N Baker College of Life Sciences, University of Leicester, Leicester, United Kingdom
Louise Kenny Faculty of Health and Life Sciences, University of Liverpool, Liverpool, UK
Jose G Cecatti Department of Obstetrics and Gynaecology, University of Campinas (UNICAMP) School of Medical Sciences, Campinas, SP, Brazil.

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Trend Prediction for Cesarean Deliveries Based on Robson Classification System at a Tertiary Referral Unit of North India

BACKGROUND

World Health Organization proposed use of Robson Classification as a global standard for assessing, maintaining and comparing Cesarean section (CS) rates. This paper aimed to examine CS trend at a tertiary center according to Robson Ten-Group Classification System (TGCS) over three-year period (2015-2017) and to predict future Cesarean trends.

METHODS

This prospective observational study was conducted at a tertiary teaching institute and included 81,784 females who delivered at this hospital over three-year duration (2015-2017). The data compilation was done according to Robson TGCS. The main outcome measures were overall annual CS rates, Robson group-wise CS rates, future overall and Robson group-wise CS trend. These parameters were calculated, trend analysis was done and trend over future 3 years was predicted.

RESULTS

There were 81,784 deliveries (62,336 vaginal and 19,448 Cesarean deliveries) over the study period. The year-wise CS rate was 22.4%, 23.5% and 25.5%, respectively. The largest contribution was by group 5 followed by group 2 and group 1. Based on 3-year data, it was predicted that CS rate will increase by 0.905% annually over coming 3 years. In groups 3, 4, 6, 7 and 8, predicted trend value showed an annual increase by 0.65%, 0.05%, 0.05%, 0.05% and 0.10%, respectively; in groups 1, 2, 5, 9 and 10, it showed an annual decrease of 0.45%, 0.05%, 1.50%, 0.50% and 0.05%, respectively.

CONCLUSION

Increasing CS rate trend was seen over last 3 years with a predicted rise of 0.905% per year. Robson groups 5, 2 and 1 were at present major contributors; however, the trend analysis predicted a decreasing trend. Trend analysis predicted annual increment in groups 3, 4, 6, 7 and 8 over next 3 years, thereby suggesting need to focus on these groups as well.

Analysis of Caesarean Section Rates Using the Robson Classification System at a University Hospital in Spain

Background: The WHO recommends the use of the Robson ten-group classification system (RTGCS) as an effective monitoring and analysis tool to assess the use of caesarean sections (CS). The present study aimed to conduct an analysis of births using the RTGCS in La Ribera University Hospital over nine years and to assess the levels and trends of CS births. Methods: Retrospective study between January 1, 2010, and December 31, 2018. All eligible women were allocated in RTGCS to determine the absolute and relative contribution made by each group to the overall CS rate; linear regression and weighted least squares regression analysis were used to analyze trends over time. The risk of CS of women with induced versus spontaneous onset of labor was calculated with an odds ratio (OR) with a 95% CI. Results: 16,506 women gave birth during the study period, 19% of them by CS. Overall, 20.4% of women were in group 1 (nulliparous, singleton cephalic, term, spontaneous labor), 29.4% in group 2 (nulliparous, singleton cephalic, term, induced labor or caesarean before labor), and 12.8% in group 4 (multiparous, singleton cephalic, term, induced or caesarean delivery before labor) made the most significant contributions to the overall rate of CS; Conclusions: In our study, Robson Groups 1, 2, and 4, were identified as the main contributors to the hospital’s overall CS rate. The RTGCS provides an easy way of collecting information about the CS rate, is a valuable clinical method that allows standardized comparison of data, and time point, and identifies the groups driving changes in CS rates.

Validation of a statistical toolkit based on the ten-group Robson Classification of cesarean delivery

OBJECTIVE

To assess the validity of a statistical toolkit based on the original ten-group Robson Classification of cesarean delivery.

METHODS

A retrospective pilot study at Al Wakra Hospital in Doha, Qatar, was conducted from June 1 to June 30, 2017, involving consecutive women undergoing cesarean delivery, using a three-stage approach. A Microsoft Excel-based toolkit was developed by dividing each of the 10 groups of the original Robson Classification into clinical groups and subgroups. A critical review of the toolkit was then undertaken by four independent physicians based on different potential clinical scenarios that could culminate in cesarean delivery in each Robson group. The toolkit was validated by populating it with the data of the cesarean deliveries of the women involved in the study.

RESULTS

The data from cesarean deliveries of 153 women were utilized in the pilot study. The toolkit catered for and successfully accommodated 94.8% of the cases without any need for change. The remaining 5.2% of cases required additional adjustments in the toolkit. The toolkit provided instant access to important data about the labor and delivery which could be used for audit and research purposes and ultimately for service improvement.

CONCLUSION

The toolkit significantly improved the clinical efficacy of the Robson Classification as a potential statistical tool for comparison of local and international data.

A before and after study of the impact on obstetric and perinatal outcomes following the introduction of an educational package of fetal heart rate monitoring education coupled with umbilical artery lactate sampling in a low resource setting labor ward in South Africa

INTRODUCTION

Rates of cesarean section (CS) are increasing and abnormal fetal heart rate tracing and concern about consequent acidosis remain one of the most common indications for primary CS. Umbilical artery (UA) lactate sampling provides clinicians with point of care feedback on CTG interpretation and intrapartum care and may result in altered future practice.

MATERIALS AND METHODS

From 3rd March - 12th November 2014 we undertook a before and after study in Pretoria, South Africa, to determine the impact of introducing a clinical package of fetal heart rate monitoring education and prompt feedback with UA cord lactate sampling, using a hand-held meter, on maternal and perinatal outcomes.

RESULTS

Nine hundred thirty-six consecutive samples were analyzed (pre n = 374 and post n = 562). There was no difference in mean lactate (4.6 mmol/L [95%CI 4.4-4.8] compared with 4.9 mmol/L [95%CI 4.7-5.1], p = 0.089). Suspected fetal compromise was reduced in the post-intervention period: 30·2% vs 22·1%, aOR 0·71, 95% CI 0·52-0·96, p = 0·027. Cesarean section rates were significantly reduced in the univariate analysis: pre- 40·3% vs post-intervention 31·6% (p = 0·007). This reduction remained significant when adjusted for previous cesarean section, primiparity, maternal HIV infection and preterm birth (aOR 0·72, 95%CI 0·54-0·98, p = 0·035). Neonatal outcomes did not differ between the two groups.

CONCLUSION

The introduction of a clinical practice package of fetal heart rate monitoring education combined with routine UA cord lactate sampling has the potential to reduce the cesarean section rate without increasing adverse neonatal outcomes in a low-resource setting.

Mode of delivery among nulliparous women with single, cephalic, term pregnancies: The WHO global survey on maternal and perinatal health, 2004-2008

OBJECTIVE

To determine risk factors associated with cesarean delivery among nulliparous women in spontaneous labor with a single, cephalic, term pregnancy (Robson group 1).

METHODS

Data were assessed from the WHO Global Survey of Maternal and Perinatal Health conducted in 2004-2008.

RESULTS

Among 82 280 women in Robson group 1, 67 698 (82.3%) had vaginal and 14 578 (17.7%) had cesarean delivery. In adjusted analyses, maternal factors associated with cesarean included age older than 18 years, being overweight or obese, being married or cohabitating, attending four prenatal visits or more, and being medically high risk (P<0.001). Women who were obstetrically high risk, referred during labor, or at 39 gestational weeks or more were also more likely to undergo cesarean (all P<0.001). Facility-level factors associated with cesarean were availability of an anesthesia service 24/7, being a teaching facility, requirement of fees for cesarean, availability of electronic fetal monitoring, and having providers skilled in operative vaginal delivery (all P<0.01).

CONCLUSION

The analysis highlights the importance of maintaining a healthy pre-pregnancy and pregnancy weight, optimizing management of women with medical problems, and ensuring clear referral mechanisms for women with intrapartum complications. The association between fees and cesarean delivery warrants further exploration.

Identifying strategies to reduce cesarean section rates by using Robson ten-group classification

OBJECTIVE

To assess the cesarean section (CS) rates using Robson ten-group classification system (RTGCS) and the interventions combined with RTGCS which may reduce the CS rates.

METHODS

A total of 100,326 deliveries at Zekai Tahir Burak Research and Training Hospital in Ankara, Turkey between 2012 and 2018 were included in this study. Interventions including free mobilization of pregnant women, CS decision with the signature of three obstetricians, re-evaluate the CS decision, strictly obeying the failed induction algorithm to reduce the CS rates were started to be applied in 2017. The CS rates between 2012 and 2017 and in 2017 were compared to evaluate the effects of the interventions on CS rate regarding the Robson groups.

RESULTS

The overall CS rates in between 2012 and 2017 significantly reduced from 37,703/84,279 (44.7%) to 6738/16,047 (42.0%) in 2017, p < .001. Cephalopelvic disproportion and suspected macrosomia rates reduced from 4992/37,703 (13.3%) to 683/6738 (10.0%), p < .001 and from 668/37,703 (1.8%) to 96/6738 (1.4%), p = .030, respectively.

CONCLUSIONS

To the best of our knowledge, this study is the first that gives the birth data from Turkey using RTGCS and showed that some interventions combined with RTGCS to reduce CS rates should be properly used.

The rate and perioperative mortality of caesarean section in Sierra Leone

Introduction

Sierra Leone has the world’s highest maternal mortality, partly due to low access to caesarean section. Limited data are available to guide improvement. In this study, we aimed to analyse the rate and mortality of caesarean sections in the country.

Methods

We conducted a retrospective study of all caesarean sections and all reported in-facility maternal deaths in Sierra Leone in 2016. All facilities performing caesarean sections were visited. Data on in-facility maternal deaths were retrieved from the Maternal Death Surveillance and Response database. Caesarean section mortality was defined as in-facility perioperative mortality.

Results

In 2016, there were 7357 caesarean sections in Sierra Leone. This yields a population rate of 2.9% of all live births, a 35% increase from 2012, with district rates ranging from 0.4% to 5.2%. The most common indications for surgery were obstructed labour (42%), hypertensive disorders (25%) and haemorrhage (22%). Ninety-nine deaths occurred during or after caesarean section, and the in-facility perioperative caesarean section mortality rate was 1.5% (median 0.7%, IQR 0–2.2). Haemorrhage was the leading cause of death (73%), and of those who died during or after surgery, 80% had general anaesthesia, 75% received blood transfusion and 22% had a uterine rupture diagnosed.

Conclusions

The caesarean section rate has increased rapidly in Sierra Leone, but the distribution remains uneven. Caesarean section mortality is high, but there is wide variation. More access to caesarean sections for maternal and neonatal complications is needed in underserved areas, and expansion should be coupled with efforts to limit late presentation, to offer assisted vaginal delivery when indicated and to ensure optimal perioperative care.

Monitoring caesarean births using the Robson ten group classification system: A cross-sectional survey of private for-profit facilities in urban Bangladesh

BACKGROUND

Globally, Caesarean section (CS) rates are mounting and currently exceed the safe upper limit of 15%. Monitoring CS rates using clinical indications and obstetric sub-group analysis could confirm that women in need have been served. In Bangladesh, the reported CS rate was 31% in 2016, and almost twice that rate in urban settings. Delivering in the private healthcare sector was a strong determinant. This study uses Robson Ten Group Classification System (TGCS) to report CS rates in urban Bangladesh. The clinical causes and determining factors for CS births have also been examined.

METHODS

This record linkage cross-sectional survey was undertaken in 34 urban for-profit private hospitals having CS facilities during the period June to August 2015. Data were supplied by inpatient case records and operation theatre registers. Descriptive analyses were performed to calculate the relative size of each group; the group-specific CS rate, and group contribution to total CS and overall CS rate. CS indications were grouped into eleven categories using ICD 10 codes. Binary logistic regression was performed to explore the determinants of CS.

RESULTS

Out of 1307 births, delivery by CS occurred in 1077 (82%). Three obstetric groups contributed the most to overall CS rate: previous CS (24%), preterm (23%) and term elective groups (22%). The major clinical indications for CS were previous CS (35%), prolonged and obstructed labor (15%), fetal distress (11%) and amniotic fluid disorder (11%). Multiple gestation, non-cephalic presentation, previous bad obstetric history were positive predictors while oxytocin used for labour induction and increased parity were negative predictors of CS.

CONCLUSIONS

As the first ever study in urban private for-profit health facilities in Bangladesh, this study usefully identifies the burden of CS and where to intervene. Engagement of multiple stakeholders including the private sector is crucial in planning effective strategies for safe reduction of CS.

Changing rates of the modes of delivery over the decades (1976, 1986, 1996, 2006, and 2016) based on the Robson-10 group classification system in a single tertiary health care center

AIM

To identify the underlying factors that may affect the changing rates of modes of delivery over the decades based on Robson-10 group classification system (TGCS) in a single tertiary health care center.

MATERIALS AND METHODS

This study included data from 10,458 deliveries in 1976, 1986, 1996, 2006, and 2016 with fetuses more than or equal to 500 g at the Department of Obstetrics and Gynecology at Hacettepe University Hospital. Patient characteristics and the mode of delivery were evaluated according to the TGCS.

RESULTS

The cesarean section (CS) rates were 11.4% (304/2668), 19.2% (459/2393), 44.7% (783/1751), 69.3% (1213/1751), and 77.9% (1477/1895) in 1976, 1986, 1996, 2006, and 2016, respectively. CS has become the preferred method of delivery for multiple pregnancies and breech presentations over the years. TGCS Group 5 was the greatest contributor to increased CS ratios. Relative contributions of TGCS Groups 1 and 3 were decreased and relative contributions of Groups 2 and 4 were increased. Operative vaginal deliveries decreased over the years.

CONCLUSION

In conclusion, effective management of labor induction, choosing vaginal delivery for appropriate breech presentations and multifetal pregnancies, proper education of obstetricians for operative vaginal delivery and objective evaluation of labor dystocia might be key points in CS rate debates.

Rising Cesarean Rates: Are Primary Sections Overused?

Doubling of C-section rates from year 2000 to 2015 globally was declared an eye-opener on October 13, 2018, in FIGO World Congress. Rapid increase in rates without clear evidence of concomitant decrease in maternal or neonatal morbidity or mortality raises significant concern that cesarean delivery is overused. This review addresses issues related to exponentially rising rates, reasons for it, and strategies to reduce. Previous cesarean delivery has main contribution to rising rates as per evidence from the literature search in last 5 years. Focus on optimizing indications of primary C-section resulted in making us rethink modifiable indications like labor dystocia, indeterminate fetal heart rate tracing, suspected fetal macrosomia, malposition, risk-adapted obstetrics, litigation fears, on demand cesarean in literate women and overuse of labor induction. Use of uniform classification system (Robson/WHO classification) with recommendations of WHO, FIGO and annual audits with cloud-based anonymous registry will streamline decisions for cesarean in nullipara and help to control the situation.

Spatial distribution of Robson 10-group classification system and poverty in southern and southeastern Brazil

OBJECTIVE

To assess the spatial distribution of the Robson 10-group classification system (TGCS) and poverty in southeastern and southern regions of Brazil in 2016.

METHODS

An ecologic study based on public data from the Brazilian Information System on Live Births and the Brazilian Institute of Geography and Statistics, including 1 519 289 (53.2%) of all live-born neonates in Brazil between January and December 2016. Statistical analysis used Bayesian modelling with spatial distribution following an autoregressive conditional structure, and Moran index.

RESULTS

In 2016, the percentage of live-born neonates delivered by cesarean was 58.8% and 60.7% in the southeastern and southern regions, respectively. Robson groups 1 and 3, involving spontaneous labor, were related to regions with higher poverty (Moran index, 0.36 and 0.44, respectively), whereas groups 2 and 5, involving cesarean delivery, were related to poorer regions (Moran index, 0.56 and 0.45, respectively).

CONCLUSION

The frequencies of each group of the Robson TGCS were heterogeneously distributed in the geographic space owing to important associations with the proportion of poverty in the different regions. Actions are needed to develop the poorest regions in order to minimize existing disparities.

Analysis of the caesarean section rate using the 10-Group Robson classification at Benha University Hospital, Egypt

BACKGROUND

Egypt has the third highest caesarean section rate (54%) in the world and lacks a standard classification system to analyse caesarean section rates. The World Health Organization (WHO) recommends the Robson classification as an effective caesarean section analysis and monitoring tool.

AIM

To analyse the caesarean section rate of Benha University Hospital, Egypt using the standard 10-Group Robson classification system.

METHOD

A prospective, cross-sectional study was conducted at the Benha University Hospital from 1 April to 30 June 2018. All women admitted for childbirth were categorised into Robson groups to determine the absolute and relative contribution made by each group to the overall caesarean section rate. Epi Data V.3.1 software programme was used to analyse the data.

FINDINGS

850 women gave birth during the study period, 466 (55%) by caesarean section (CS). Robson Group 5 (multiparous, term, cephalic presentation and previous caesarean section) contributed the most (36%) to the overall CS rate. 175/308 (56%) women in this group had previously undergone one caesarean section. Group 6 (all nulliparous women with single breech pregnancy) and Group10 (cephalic preterm pregnancies) were the second and the third greatest contributors toward the overall CS rate, with 4.6% and 2.8% respectively.

CONCLUSIONS

In keeping with other studies, Groups 5, 6, and 10 were the main contributors to the overall caesarean section rate. We found Robson classification to be clinically relevant and an effective tool to analyse the caesarean section rate even in settings with limited resources.

Length of stay following cesarean sections: A population based study in the Friuli Venezia Giulia region (North-Eastern Italy), 2005-2015

BACKGROUND

Births by cesarean section (CS) usually require longer recovery time, and as a result women remain hospitalized longer following CS than vaginal delivery (VD). A number of strategies have been proposed to reduce avoidable health care costs associated with childbirth. Among these, the containment of length of hospital stay (LoS) has been identified as an important quality indicator of obstetric care and performance efficiency of maternity centres. Since improvement of obstetric care at hospital level needs quantitative evidence, we compared the maternity services of an Italian region on LoS post CS.

METHODS

We conducted a population-based study in Friuli Venezia Giulia (FVG), a region of North-Eastern Italy, collecting data from all its 12 maternity centres (coded from A to K) during 2005-2015. We fitted a multivariable logistic regression using LoS as a binary outcome, higher/lower than the international early discharge (ED) cutoffs for CS (4 days), controlling for hospitals as well as several factors related to the clinical conditions of the mothers and the newborn, the obstetric history and socio-demographic background. Results were expressed as adjusted odds ratios (aOR) with 95% confidence interval (95%CI). Population attributable risks (PARs) were also calculated as proportional variation of LoS>ED for each hospital in the ideal scenario of having the same performance as centre J (the reference) during calendar year 2015. Results were expressed as PAR with 95%CI. Differences in mean LoS were also investigated with a multivariable linear regression model including the same explanatory factors of the above multiple logistic regression. Results were expressed as adjusted regression coefficients (aRC) with 95%CI.

RESULTS

Although decreasing over the years (5.0 ± 1.7 days in 2005 vs. 4.4 ± 1.7 days in 2015), the pooled mean LoS in the whole FVG during these 11 years was still 4.7 ± 1.7 days, higher than respective international ED benchmark. The significant decreasing trend of LoS>ED over time in FVG (aOR = 0.89; 95%CI: 0.88; 0.90) was marginal as compared to the variability of LoS>ED observed among the various maternity services. Regardless it was expressed as aRC or aOR, LoS after CS was lowest in hospital C, highest in hospital D and intermediate in centres I, K, G, F, A, H, E, B and J (in descending order). The aOR of LoS being longer than ED ranged from 1.63 (95%CI:1.46; 1.81) in hospital B up to 32.09 (95%CI: 25.68; 40.10) in facility D. When hospitals were ranked by PAR the same pattern was found, even if restricting the analysis to low risk pregnancies.

CONCLUSIONS

Although significantly decreasing over time, the mean LoS in FVG during 2005-2015 was 4.7 days, higher than the international threshold recommended for CS. There was substantial variability in LoS by facility centre, suggesting that internal organizational processes of single hospitals should be improved by enforcing standardized guidelines and using audits, economic incentives and penalties if need be.

An approach to identify a minimum and rational proportion of caesarean sections in resource-poor settings: a global network study

Background

Caesarean section prevalence is increasing in Asia and Latin America while remaining low in most African regions. Caesarean section delivery is effective for saving maternal and infant lives when they are provided for medically-indicated reasons. On the basis of ecological studies, caesarean delivery prevalence between 9% and 19% has been associated with better maternal and perinatal outcomes, such as reduced maternal land fetal mortality. However, the specific prevalence of obstetric and medical complications that require caesarean section have not been established, especially in low-income and middle-income countries (LMICs). We sought to provide information to inform the approach to the provision of caesarean section in low-resource settings.

Methods

We did a literature review to establish the prevalence of obstetric and medical conditions for six potentially life-saving indications for which caesarean section could reduce mortality in LMICs. We then analysed a large, prospective population-based dataset from six LMICs (Argentina, Guatemala, Kenya, India, Pakistan, and Zambia) to determine the prevalence of caesarean section by indication for each site. We considered that an acceptable number of events would be between the 25th and 75th percentile of those found in the literature.

Findings

Between Jan 1, 2010, and Dec 31, 2013, we enrolled a total of 271 855 deliveries in six LMICs (seven research sites). Caesarean section prevalence ranged from 35% (3467 of 9813 deliveries in Argentina) to 1% (303 of 16 764 deliveries in Zambia). Argentina’s and Guatemala’s sites all met the minimum 25th percentile for five of six indications, whereas sites in Zambia and Kenya did not reach the minimum prevalence for caesarean section for any of the indications. Across all sites, a minimum overall caesarean section of 9% was needed to meet the prevalence of the six indications in the population studied.

Interpretation

In the site with high caesarean section prevalence, more than half of the procedures were not done for life-saving conditions, whereas the sites with low proportions of caesarean section (below 9%) had an insufficient number of caesarean procedures to cover those life-threatening causes. Attempts to establish a minimum caesarean prevalence should go together with focusing on the life-threatening causes for the mother and child. Simple methods should be developed to allow timely detection of life-threatening conditions, to explore actions that can remedy those conditions, and the timely transfer of women with those conditions to health centres that could provide adequate care for those conditions.

Use of a criteria-based audit to optimize uptake of cesarean delivery in a low-resource setting

OBJECTIVE

To evaluate the impact of a criteria-based audit (CBA) of obstructed labor and fetal distress on cesarean delivery and perinatal outcomes.

METHODS

A cross-sectional study was performed at a tertiary referral hospital in Tanzania. Data were collected before and after CBA (January 2013-November 2013 and July 2015-June 2016). Outcomes of fetal distress (baseline CBA, n=248; re-audit, n=251) and obstructed labor (baseline CBA, n=260; re-audit n=250) were assessed using a checklist. Additionally, 27 960 parturients were assessed using the Robson classification.

RESULTS

Perinatal morbidity and mortality decreased from 42 of 260 (16.2%) to 22 of 250 (8.8%) among patients with obstructed labor after CBA (P=0.012). Cesarean delivery rate decreased for referred term multiparas with induced labor or prelabor cesarean delivery (odds ratio [OR] 0.28, 95% confidence interval [CI] 0.09-0.82). Cesarean delivery rate for preterm pregnancies increased among both referred (OR 1.28, 95% CI 1.02-1.63) and non-referred (OR 2.78, 95% CI 1.98-3.90) groups. Neonatal distress rate decreased for referred term multiparas (OR 0.72, 95% CI 0.56-0.92), referred preterm pregnancies (OR 0.32, 95% CI 0.25-0.39), and non-referred preterm pregnancies (OR 0.26, 95% CI 0.18-0.36).

CONCLUSION

Use of CBA reduced poor perinatal outcomes of obstructed labor and increased uptake of cesarean delivery.

Cesarean rates in a Chilean public hospital and the use of a new prioritization criteria: The relevance index

AIM

Cesarean section rates are increasing worldwide and Robson's classification system allows a practical approach to study this phenomenon. C-section in Chile has been indicated as unexpectedly high, with important variability within the country and payment systems. The aim was to report our data using Robson's system and the evolution of local C-section rate in a public hospital during a 9-year period.

METHODS

Retrospective analysis (2005-April 2014), in a metropolitan hospital in Santiago. All deliveries were classified into Robson groups. Time changes were analyzed with Pearson's correlation. P value <0.05 was considered significant. A 'relevance index' (RI) for each group was calculated as 100 × C-S rate × relative contribution.

RESULTS

The overall C-section rate increased from 24 to 27% (P < 0.05) in 53 571 deliveries, with a greater increase in groups 1 (nulliparous, single, term cephalic, spontaneous labor), 3 (multiparous, single, no previous C-S, term cephalic, spontaneous labor) and 4 (multiparous, single, no previous C-S, term cephalic, induced or no labor). Despite no increase in Group 5 (women with one or more previous C-S) this group had the highest RI (20.3), which defined priority for intervention over others.

CONCLUSION

C-S rate was lower than that reported in other centers from Chile and Latin America. Robson's classification and the RI allowed prioritization. Although increase in groups 1, 3 and 4, group 5 needs attention because of stronger impact on overall C-S rate. This analysis allowed to define how to lower C-S rate in our institution.

'If I do 10-15 normal deliveries in a month I hardly ever sleep at home.' A qualitative study of health providers' reasons for high rates of caesarean deliveries in private sector maternity care in Delhi, India

Background

Although the overall rate of caesarean deliveries in India remains low, rates are higher in private than in public facilities. In a household survey in Delhi, for instance, more than half of women delivering in private facilities reported a caesarean section. Evidence suggests that not all caesarean sections are clinically necessary and may even increase morbidity. We present providers’ perspectives of the reasons behind the high rates of caesarean births in private facilities, and possible solutions to counter the trend.

Methods

Fourteen in-depth interviews were conducted with high-end private sector obstetricians and other allied providers in Delhi and its neighbouring cities, Gurgaon and Ghaziabad.

Results

Respondents were of the common view that private sector caesarean rates were unreasonably high and perceived time and doctors’ convenience as the foremost reasons. Financial incentives had an indirect effect on decision-making. Obstetricians felt that they must maintain high patient loads to be commercially successful. Many alluded to their busy working lives, which made it challenging for them to monitor every delivery individually. Besides fearing for patient safety in these situations, they were fearful of legal action if anything went wrong. A lack of context specific guidelines and inadequate support from junior staff and nurses exacerbated these problems. Maternal demand also played a role, as the consumer-provider relationship in private healthcare incentivised obstetricians to fulfil patient demands for caesarean section. Suggested solutions included more support, from either well-trained midwives and junior staff or using a ‘shared practice’ model; guidelines introduced by an Indian body; increased regulation within the sector and public disclosure of providers’ caesarean rates.

Conclusions

Commercial interests contribute indirectly to high caesarean rates, as solo obstetricians juggle the need to maintain high patient loads with inadequate support staff. Perceptions amongst providers and consumers of caesarean section as the ‘safe’ option have re-defined caesareans as the new ‘normal’, even for low-risk deliveries. At the policy level, guidelines and public disclosures, strong initiatives to develop professional midwifery, and increasing public awareness, could bring about a sustainable reduction in the present high rates.

Impact of prenatal exercise on maternal harms, labour and delivery outcomes: a systematic review and meta-analysis

OBJECTIVE

To perform a systematic review of the relationships between prenatal exercise and maternal harms including labour/delivery outcomes.

DESIGN

Systematic review with random effects meta-analysis and meta-regression.

DATASOURCES

Online databases were searched up to 6 January 2017.

STUDY ELIGIBILITY CRITERIA

Studies of all designs were included (except case studies) if they were published in English, Spanish or French and contained information on the population (pregnant women without contraindication to exercise), intervention (subjective or objective measures of frequency, intensity, duration, volume or type of exercise), comparator (no exercise or different frequency, intensity, duration, volume and type of exercise, alone ["exercise-only"] or in combination with other intervention components [e.g., dietary; "exercise + co-intervention"]) and outcome (preterm/prelabour rupture of membranes, caesarean section, instrumental delivery, induction of labour, length of labour, vaginal tears, fatigue, injury, musculoskeletal trauma, maternal harms (author defined) and diastasis recti).

RESULTS

113 studies (n=52 858 women) were included. 'Moderate' quality evidence from exercise-only randomised controlled trials (RCTs) indicated a 24% reduction in the odds of instrumental delivery in women who exercised compared with women who did not (20 RCTs, n=3819; OR 0.76, 95% CI 0.63 to 0.92, I ²= 0 %). The remaining outcomes were not associated with exercise. Results from meta-regression did not identify a dose-response relationship between frequency, intensity, duration or volume of exercise and labour and delivery outcomes.

SUMMARY/CONCLUSIONS

Prenatal exercise reduced the odds of instrumental delivery in the general obstetrical population. There was no relationship between prenatal exercise and preterm/prelabour rupture of membranes, caesarean section, induction of labour, length of labour, vaginal tears, fatigue, injury, musculoskeletal trauma, maternal harms and diastasis recti.

Global epidemiology of use of and disparities in caesarean sections

In this Series paper, we describe the frequency of, trends in, determinants of, and inequalities in caesarean section (CS) use, globally, regionally, and in selected countries. On the basis of data from 169 countries that include 98·4% of the world's births, we estimate that 29·7 million (21·1%, 95% uncertainty interval 19·9-22·4) births occurred through CS in 2015, which was almost double the number of births by this method in 2000 (16·0 million [12·1%, 10·9-13·3] births). CS use in 2015 was up to ten times more frequent in the Latin America and Caribbean region, where it was used in 44·3% (41·3-47·4) of births, than in the west and central Africa region, where it was used in 4·1% (3·6-4·6) of births. The global and regional increases in CS use were driven both by an increasing proportion of births occurring in health facilities (accounting for 66·5% of the global increase) and increases in CS use within health facilities (33·5%), with considerable variation between regions. Based on the most recent data available for each country, 15% of births in 106 (63%) of 169 countries were by CS, whereas 47 (28%) countries showed CS use in less than 10% of births. National CS use varied from 0·6% in South Sudan to 58·1% in the Dominican Republic. Within-country disparities in CS use were also very large: CS use was almost five times more frequent in births in the richest versus the poorest quintiles in low-income and middle-income countries; markedly high CS use was observed among low obstetric risk births, especially among more educated women in, for example, Brazil and China; and CS use was 1·6 times more frequent in private facilities than in public facilities.

A national measure to reduce primary cesarean rates in Turkey

Purpose: To examine the influence of the "Physician Unit Performance Coefficient" (PUPC) regulation, taken into force by the TR Ministry of Health in January 2013 in our country, based on the cesarean rates in our clinic.Methods: The pregnant women who gave birth at the Diyarbakır Maternity and Pediatrics Hospital within a period of three years before the PUPC has been taken into force and the pregnant women who have birth within a period of three years after January 2013, when the regulation has been taken into force, have been divided into two groups as Group 1 and Group 2, respectively. Comparisons have been made between the two groups with respect to primary cesarean, total cesarean, neonatal mortality, and maternal mortality rates.Results: From the 125,816 pregnant women who gave birth between February 2010 and January 2016, 58,856 (46.7%) are included in Group 1 and the remaining 66,960 (53.3%) are in Group 2. The total Cesarean Rate is 27% in Group 2 and 24.8% in Group 1. The primary Cesarean Rate is 11.3% in Group 2 and 13.5% in Group 1. The neonatal mortality rate is 7.81‰ in Group 2 and 10‰ in Group 1. The differences in the total cesarean rates, primary cesarean rates and neonatal mortality rates have been found statistically significant. Maternal mortality rates have been found to be 5.1 in 100,000 in Group one and 4.48 in 100,000 in Group 2 and the difference between the two groups has not been found as statistically significant.Conclusions: A meaningful reduction has been achieved in the primary cesarean rates without increasing maternal and neonatal mortality rates after the PUPC, implemented by the TR Ministry of Health, has been taken into force.

Prevalence of and reasons for women's, family members', and health professionals' preferences for cesarean section in China: A mixed-methods systematic review

BACKGROUND

China has witnessed a rapid increase of cesarean section (CS) rates in recent years. Several non-clinical factors have been cited as contributing to this trend including maternal request and perceived convenience. We aimed to assess preferences for mode of delivery and reasons for preferences for CS in China to inform the development of future interventions to mitigate unnecessary CSs, which are those performed in the absence of medical indications.

METHODS AND FINDINGS

We conducted a mixed-methods systematic review and included longitudinal, cross-sectional, and qualitative studies in mainland China, Hong Kong, and Taiwan that investigated preferences for mode of delivery among women and family members and health professionals, and the reasons underlying such preferences. We searched MEDLINE/PubMed, Embase, CINAHL, POPLINE, PsycINFO, Global Health Library, and one Chinese database (CNKI) using a combination of the key terms 'caesarean section', 'preference', 'choice', 'knowledge', 'attitude', 'culture', 'non-clinical factors', and 'health professionals-patient relations' between 1990 and 2018 without language restriction. Meta-analysis of quantitative studies and meta-synthesis of qualitative studies were applied. We included 66 studies in this analysis: 47 quantitative and 19 qualitative. For the index pregnancy, the pooled proportions of preference for CS reported by women in longitudinal studies were 14% in early or middle pregnancy (95% CI 12%-17%) and 21% in late pregnancy (95% CI 15%-26%). In cross-sectional studies, the proportions were 17% in early or middle pregnancy (95% CI 14%-20%), 22% in late pregnancy (95% CI 18%-25%), and 30% postpartum (95% CI 19%-40%). Women's preferences for CS were found to rise as pregnancy progressed (preference change across longitudinal studies: mean difference 7%, 95% CI 1%-13%). One longitudinal study reported that the preference for CS among women's partners increased from 8% in late pregnancy to 17% in the immediate postpartum period. In addition, 18 quantitative studies revealed that some pregnant women, ranging from 4% to 34%, did not have a straightforward preference for a mode of delivery, even in late pregnancy. The qualitative meta-synthesis found that women's perceptions of CS as preferable were based on prioritising the baby's and woman's health and appeared to intensify through interactions with the health system. Women valued the convenience of bypassing labour because of fear of pain, antagonistic relations with providers, and beliefs of deteriorating quality of care during labour and vaginal birth, fostering the feeling that CS was the safest option. Health professionals' preference for CS was influenced by financial drivers and malpractice fears. This review has some limitations, including high heterogeneity (despite subgroup and sensitivity analysis) in the quantitative analysis, and the potential for over-reporting of women's preferences for CS in the qualitative synthesis (due to some included studies only including women who requested CS).

CONCLUSIONS

Despite a minority of women expressing a preference for CS, individual, health system, and socio-cultural factors converge, contributing to a high CS rate in mainland China, Hong Kong, and Taiwan. In order to reduce unnecessary CSs, interventions need to address all these non-clinical factors and concerns.

SYSTEMATIC REVIEW REGISTRY

Prospero CRD42016036596.

Non-clinical interventions to reduce unnecessary caesarean section targeted at organisations, facilities and systems: Systematic review of qualitative studies

OBJECTIVE

When medically indicated, caesarean section can prevent deaths and other serious complications in mothers and babies. Lack of access to caesarean section may result in increased maternal and perinatal mortality and morbidity. However, rising caesarean section rates globally suggest overuse in healthy women and babies, with consequent iatrogenic damage for women and babies, and adverse impacts on the sustainability of maternity care provision. To date, interventions to ensure that caesarean section is appropriately used have not reversed the upward trend in rates. Qualitative evidence has the potential to explain why and how interventions may or may not work in specific contexts. We aimed to establish stakeholders' views on the barriers and facilitators to non-clinical interventions targeted at organizations, facilities and systems, to reduce unnecessary caesarean section.

METHODS

We undertook a systematic qualitative evidence synthesis using a five-stage modified, meta-ethnography approach. We searched MEDLINE, CINAHL, PsychINFO, EMBASE and grey literature databases (Global Index Medicus, POPLINE, AJOL) using pre-defined terms. Inclusion criteria were qualitative and mixed-method studies, investigating any non-clinical intervention to reduce caesarean section, in any setting and language, published after 1984. Study quality was assessed prior to data extraction. Interpretive thematic synthesis was undertaken using a barriers and facilitators lens. Confidence in the resulting Summaries of Findings was assessed using GRADE-CERQual.

RESULTS

8,219 studies were identified. 25 studies were included, from 17 countries, published between 1993-2016, encompassing the views of over 1,565 stakeholders. Nineteen Summary of Findings statements were derived. They mapped onto three distinct themes: Health system, organizational and structural factors (6 SoFs); Human and cultural factors (7 SoFs); and Mechanisms of effect to achieve change factors (6 SoFs). The synthesis showed how inter- and intra-system power differentials, and stakeholder commitment, exert strong mechanisms of effect on caesarean section rates, independent of the theoretical efficacy of specific interventions to reduce them.

CONCLUSIONS

Non-clinical interventions to reduce caesarean section are strongly mediated by organisational power differentials and stakeholder commitment. Barriers may be greatest where implementation plans contradict system and cultural norms.

PROTOCOL REGISTRATION

PROSPERO: CRD42017059456.

Ability of women to self-classify into the Robson ten-group classification system

OBJECTIVE

Recent guidelines from WHO and the International Federation of Gynecology and Obstetrics (FIGO) state that the Robson ten-group classification system (TGCS) should be universally applied to pregnant women. Such information might enable women to make an informed decision about the place and mode of delivery. We assessed whether women could self-classify correctly according to the TGCS.

METHODS

A prospective study was conducted in a tertiary level maternity hospital between March 6 and July 31, 2017. We included post-partum women admitted to the puerperium ward. Participants were instructed to complete a multiple-choice questionnaire with a simplified description of TGCS and to classify themselves into one of the ten groups. A practitioner reclassified women into the correct TGCS group. Cohen κ was applied to measure the rate of agreement between these two evaluations.

RESULTS

400 women were enrolled, with a global rate of agreement of 81.8% between women's self-evaluation and the evaluation by the practitioner. A subanalysis showed that the highest rate of agreement was among the group with higher level education (84.0%).

CONCLUSION

Women of different ages and education backgrounds were able to correctly classify themselves into the TGCS. The higher the educational level, the greater the rate of agreement.

Role of maternal characteristics and epidural analgesia on caesarean section rate in groups 1 and 3 according to Robson's classification: a cohort study in an Italian university hospital setting

OBJECTIVE

To investigate the role of maternal characteristics and epidural analgesia (EA) on caesarean section (CS) rates in selected groups by using the Robson 10-Group Classification System (RTGCS).

DESIGN

Cohort study.

SETTING

Department of Obstetrics and Gynaecology, Fondazione Policlinico Universitario 'A. Gemelli', Rome, Italy.

PATIENTS

A total of 12 098 deliveries in periods I (1998-1999) and II (2010-2011).

MAIN OUTCOME MEASURES

CS rates in groups 1 and 3 of RTGCS.

RESULTS

In group 1, 1144 (20%) patients were assigned to period I and 1302 (20.4%) to period II, while in group 3, 1587 (27.8%) were assigned to period I and 1502 (23.5%) to period II. CS rates were 16.4% and 23.1% in group 1 and 12.7% and 10.9% in group 3 in periods I and II, respectively. In group 1, significant and independent contributions to CS rate were provided by maternal age (p=0.018; OR 0.95 (95% CI 0.85 to 0.97)), body mass index (BMI) (p=0.022; OR 0.89 (95% CI 0.85 to 0.91)) and EA administration (p=0.037; OR 0.59 (95% CI 0.43 to 0.77)). In group 3, maternal age (p<0.001; OR 0.93 (95% CI 0.89 to 0.96)) and BMI (p=0.023; OR 0.98 (95% CI 0.96 to 0.99)) were found to be significantly associated with CS.

CONCLUSIONS

RTGCS is an effective tool for analysing changes in obstetric care, allowing for the recognition of maternal age, BMI and EA administration in the strategic planning for mitigation of CS rates in selected groups.

Factors Associated with Trial of Labour and Mode of Delivery in Robson Group 5: A Select Group of Women With Previous Caesarean Section

OBJECTIVE

To determine the proportion of women in Robson group 5 (RG5) who were eligible for a trial of labour after Caesarean (TOLAC) and, among eligible candidates, identify determinants of having a TOLAC and subsequent vaginal delivery (VD).

METHODS

This population-based cohort study used data derived from the Nova Scotia Atlee Perinatal Database. Deliveries from 1998-2014 to women in RG5 (≥1 previous CS with a singleton term cephalic fetus) were included. Eligibility for a TOLAC was based on SOGC criteria. Multivariable logistic regression was used to identify characteristics independently associated with TOLAC and VD. The characteristics associated with VD were used in a logistic model to predict the theoretical probability of VD in women who did not have a TOLAC.

RESULTS

Of the 15 111 deliveries in RG5, 75.3% were by CS. Of the 14 763 eligible women, 5488 (37.2%) had a TOLAC, of which 3739 (68.1%) resulted in VD. Predictors of VD included high area-level income and either a CS without labour or a spontaneous VD in the preceding pregnancy. While mode of previous delivery also predicted TOLAC among eligible women, high area-level income was associated with reduced odds of TOLAC. The probability of VD in women who did not undergo TOLAC was estimated to be 47.1%, and the lowest CS rate attainable in RG5 was estimated at 46.3%.

CONCLUSIONS

Sociodemographic factors such as income and previous mode of delivery were associated with the rates of TOLAC and subsequent VD in eligible women, and suggest that the Caesarean section rate in RG5 could be safely reduced.

Robson 10-groups classification system to access C-section in two public hospitals of the Federal District/Brazil

BACKGROUND

The global increase in C-section rates is real. In Brazil, these indices correspond to 58.94% in the Midwest region and 52.77% in the Federal District.

OBJECTIVE

To evaluate the C-section rates and identify the groups with the greatest risk at two reference hospitals in the public network of Federal District/Brazil, using 10-Group Robson System.

METHOD

A cross-sectional study of 6579 births assisted at the Hospital A (HA) and the Hospital B (HB) during 2013. The C-section rates in each group and its respective contribution to the total hospital C-sections was compared between HA and HB. To this, was used the proportion difference test (similar to chi-square test), with RR and 95% CI, and the logistic regression analysis (OR; 95% CI) among the groups with higher C-section/total C-section. The significance limit of p < 0.05 was defined for all tests.

RESULTS

The C-section rates were 50.8% at the HA and 42.3% at the HB, with 1.20 RR (95%CI = 1.13-1.28) at the HA. The highest rates were observed in Robson groups G5, G1, and G2. At the HA, G1 had a 21.5% C-section rate, which was greater than at the HB (13.8%; p < 0.05); the cesarean rates for groups G2 and G5 were higher at the HB (respectively, 18.6 and 38.1%) than at the HA (14.8 and 32.5%, respectively; p < 0.05).

CONCLUSION

These results point out specific goals to be achieved in order to reduce abusive cesarean rates in both A and B hospitals, especially in the primigravida and in those with previous C-section.

Cesarean section and diabetes during pregnancy: An NSW population study using the Robson classification

AIM

The aim of this study was to identify the main contributors to cesarean section (CS) among women with and without diabetes during pregnancy using the Robson classification and to compare CS rates within Robson groups.

METHODS

A population-based cohort study was conducted of all women who gave birth in New South Wales, Australia, between 2002 and 2012. Women with pregestational diabetes (types 1 and 2) and gestational diabetes mellitus (GDM) were grouped using the Robson classification. Adjusted odd ratios (AOR) and 95% confidence intervals (CI) were calculated using multivariable logistic regression.

RESULTS

The total CS rate was 53.6% for women with pregestational diabetes, 36.8% for women with GDM and 28.5% for women without diabetes. Previous CS contributed the most to the total number of CS in all populations. For preterm birth, the contribution to the total was 20.5% for women with pregestational diabetes and 5.7% for women without diabetes. Compared to women without diabetes, for nulliparous with pregestational diabetes, the odds of CS was 1.4 (95% CI, 1.1-1.8) for spontaneous labor and 2.0 (95% CI, 1.7-2.3) for induction of labor.

CONCLUSION

A history of CS was the main contributor to the total CS. Reducing primary CS is the first step to lowering the high rate of CS among women with diabetes. Nulliparous women were more likely to have CS if they had pregestational diabetes. This increase was also evident in all multiparous women giving birth. The high rate of preterm births and CS reflects the clinical issues for women with diabetes during pregnancy.

Within country inequalities in caesarean section rates: observational study of 72 low and middle income countries

OBJECTIVE

To provide an update on economic related inequalities in caesarean section rates within countries.

DESIGN

Secondary analysis of demographic and health surveys and multiple indicator cluster surveys.

SETTING

72 low and middle income countries with a survey conducted between 2010 and 2014 for analysis of the latest situation of inequality, and 28 countries with a survey also conducted between 2000 and 2004 for analysis of the change in inequality over time.

PARTICIPANTS

Women aged 15-49 years with a live birth during the two or three years preceding the survey.

MAIN OUTCOME MEASURES

Data on caesarean section were disaggregated by asset based household wealth status and presented separately for five subgroups, ranging from the poorest to the richest fifth. Absolute and relative inequalities were measured using difference and ratio measures. The pace of change in the poorest and richest fifths was compared using a measure of excess change.

RESULTS

National caesarean section rates ranged from 0.6% in South Sudan to 58.9% in the Dominican Republic. Within countries, caesarean section rates were lowest in the poorest fifth (median 3.7%) and highest in the richest fifth (median 18.4%). 18 out of 72 study countries reported a difference of 20 percentage points or higher between the richest and poorest fifth. The highest caesarean section rates and greatest levels of absolute inequality were observed in countries from the region of the Americas, whereas countries from the African region had low levels of caesarean use and comparatively lower levels of absolute inequality, although relative inequality was quite high in some countries. 26 out of 28 countries reported increases in caesarean section rates over time. Rates tended to increase faster in the richest fifth (median 0.9 percentage points per year) compared with the poorest fifth (median 0.2 percentage points per year), indicating an increase in inequality over time in most of these countries.

CONCLUSIONS

Substantial within country economic inequalities in caesarean deliveries remain. These inequalities might be due to a combination of inadequate access to emergency obstetric care among the poorest subgroups and high levels of caesarean use without medical indication in the richest subgroups, especially in middle income countries. Country specific strategies should address these inequalities to improve maternal and newborn health.

Management of anaesthesia for elective, low-risk (Category 4) caesarean section

An increasing number of caesarean sections are being performed for both elective as well as emergency cases. Category 4 caesarean section refers to a planned elective surgery after 39 weeks of gestation at a time suitable to the mother and the maternity team. For a safe conduct of anaesthesia, the updated obstetric anaesthesia guidelines recommend administration of neuraxial anaesthesia, whenever feasible. The management should include adequate postoperative pain relief, early ambulation, and thromboprophylaxis to ensure early recovery. This review will discuss the anaesthetic management including regional anaesthesia, general anaesthesia, and postoperative analgesia for elective, low-risk (Category 4) caesarean section.

An implementation algorithm to improve skin-to-skin practice in the first hour after birth

Evidence supporting the practice of skin‐to‐skin contact and breastfeeding soon after birth points to physiologic, social, and psychological benefits for both mother and baby. The 2009 revision of Step 4 of the WHO/UNICEF “Ten Steps to Successful Breastfeeding” elaborated on the practice of skin‐to‐skin contact between the mother and her newly born baby indicating that the practice should be “immediate” and “without separation” unless documented medically justifiable reasons for delayed contact or interruption exist. While in immediate, continuous, uninterrupted skin‐to‐skin contact with mother in the first hour after birth, babies progress through 9 instinctive, complex, distinct, and observable stages including self‐attachment and suckling. However, the most recent Cochrane review of early skin‐to‐skin contact cites inconsistencies in the practice; the authors found “inadequate evidence with respect to details … such as timing of initiation and dose.” This paper introduces a novel algorithm to analyse the practice of skin to skin in the first hour using two data sets and suggests opportunities for practice improvement. The algorithm considers the mother's Robson criteria, skin‐to‐skin experience, and Widström's 9 Stages. Using data from vaginal births in Japan and caesarean births in Australia, the algorithm utilizes data in a new way to highlight challenges to best practice. The use of a tool to analyse the implementation of skin‐to‐skin care in the first hour after birth illuminates the successes, barriers, and opportunities for improvement to achieving the standard of care for babies. Future application should involve more diverse facilities and Robson's classifications.

Cesarean rates and severe maternal and neonatal outcomes according to the Robson 10-Group Classification System in Khon Kaen Province, Thailand

OBJECTIVE

To assess cesarean rates and maternal and neonatal outcomes in each group in the Robson 10-Group Classification System (TGCS).

METHODS

In a cross-sectional study, data were reviewed from all pregnant women who delivered at 24 government hospitals in Khon Kaen Province, Thailand, in 2014. Delivery and perinatal outcomes were recorded.

RESULTS

Of 18 043 deliveries, 5666 (31.4%) were by cesarean. Women in group 5 (previous cesarean) accounted for the most cesareans (1472, 26.0%). Groups 1 and 2 (nulliparous women) accounted for 2355 (41.6%) of procedures; the rate of cesarean within these two groups was 19.4% (1162/5981) and 71.2% (1193/1675), respectively. As compared with group 1, women in groups 2, 4, 6, 7, and 10 had significantly increased risk of severe maternal outcomes, and those in groups 6, 7, 8, 9, and 10 had an increased risk of severe neonatal outcomes.

CONCLUSION

The rate of cesarean in the study setting was high, and three out of four procedures were performed for women in groups 5, 1, and 2. Interventions should be focused on these groups to reduce the overall cesarean rates.

Audit and feedback using the Robson classification to reduce caesarean section rates: a systematic review

BACKGROUND

In most regions worldwide, caesarean section (CS) rates are increasing. In these settings, new strategies are needed to reduce CS rates.

OBJECTIVES

To identify, critically appraise and synthesise studies using the Robson classification as a system to categorise and analyse data in clinical audit cycles to reduce CS rates.

SEARCH STRATEGY

Medline, Embase, CINAHL and LILACS were searched from 2001 to 2016.

SELECTION CRITERIA

Studies reporting use of the Robson classification to categorise and analyse data in clinical audit cycles to reduce CS rates.

DATA COLLECTION

Data on study design, interventions used, CS rates, and perinatal outcomes were extracted.

RESULTS

Of 385 citations, 30 were assessed for full text review and six studies, conducted in Brazil, Chile, Italy and Sweden, were included. All studies measured initial CS rates, provided feedback and monitored performance using the Robson classification. In two studies, the audit cycle consisted exclusively of feedback using the Robson classification; the other four used audit and feedback as part of a multifaceted intervention. Baseline CS rates ranged from 20 to 36.8%; after the intervention, CS rates ranged from 3.1 to 21.2%. No studies were randomised or controlled and all had a high risk of bias.

CONCLUSION

We identified six studies using the Robson classification within clinical audit cycles to reduce CS rates. All six report reductions in CS rates; however, results should be interpreted with caution because of limited methodological quality. Future trials are needed to evaluate the role of the Robson classification within audit cycles aimed at reducing CS rates.

TWEETABLE ABSTRACT

Use of the Robson classification in clinical audit cycles to reduce caesarean rates.

Impact of antenatal oxytocin infusion on neonatal respiratory morbidity associated with elective cesarean section

INTRODUCTION

This study was designed to estimate respiratory morbidity associated with elective cesarean section (ECS) and to determine the effect of antenatal oxytocin exposure on this morbidity.

MATERIAL AND METHODS

Nine hundred and sixty-five neonates ≥ 37 weeks' gestation delivered by cesarean section during 1 year were included in this retrospective study and classified into two groups according to oxytocin exposure before cesarean deliveries. Respiratory morbidity for each group was recorded and statistically analyzed.

RESULTS

Transient tachypnea of newborn (TTN) was significantly more frequent in group II (ECS group) than in group I (cesarean section after oxytocin exposure) (8.19% vs. 2.92%; respectively, p = 0.0006). Mechanical ventilation, continuous positive airway pressure (CPAP) and oxygen therapy were significantly more frequent in group II than in group I (1.78%, 2.14% and 4.28% versus 0.44%, 0.58% and 1.46%, respectively; p = 0.039, and p = 0.033 and p = 0.009, respectively). The number of newborns admitted to the neonatal unit and neonatal intensive care unit (NICU) was significantly higher in group II than in group I (6.41% and 2.14% vs. 2.05% and 0.58%, respectively; p = 0.001 and p = 0.033, respectively). Surfactant, fluid therapies and parenteral nutrition were significantly more frequent in group II than in group I (2.14%, 4.28% and 2.49% vs. 0.15%, 1.46% and 0.73%, respectively; p = 0.001, p = 0.009 and p = 0.02, respectively).

CONCLUSIONS

Neonatal respiratory morbidity associated with ECS significantly decreased after antenatal oxytocin exposure. A significant reduction of neonatal respiratory morbidity would be achieved if ECS were performed after 39 weeks' gestation.

Indications for Cesarean Delivery in Mexico: Evaluation of Appropriate Use and Justification

BACKGROUND

Cesarean delivery is one of the most widely used surgical interventions in Latin America and in many cases it is performed with no clear medical indication. Our objective was to analyze the relationship between reported indications for a cesarean and support for that indication in the clinical record in four Mexican hospitals, during the 2006-2007 period.

METHODS

The data are from 604 (37.1%) women from a total of 1,625 who were admitted to the hospital in labor, and who gave birth through cesarean. Multivariate logistical regression analysis was used to explore the association between indications for clinically justified or unjustified surgery and other clinical and sociodemographic variables.

RESULTS

Supporting clinical information for indications of cesarean delivery were found in only 45 percent of the cases considered. The adjusted statistical analysis showed that the variables associated with an unjustified indication for cesarean were: not having had a prior birth (OR 1.84 [95% CI 1.16-2.89]), having a maximum cervical dilation of 4 centimeters or less at time of cesarean (OR 2.44 [95% CI 1.53-3.87]), and having received care in a private hospital (OR 6.11 [95% CI 1.90-19.57]).

DISCUSSION

The indications for cesarean related to labor dynamics were those least supported. Not having had a prior birth poses the greatest risk of having a poorly supported indication for a cesarean delivery. It would be prudent to institute audits, and greater requirements for and surveillance of documentation for cesarean delivery indications.