Usefulness of the WHO C-Model to optimize the cesarean delivery rate in a tertiary hospital setting

Achievement of appropriate cesarean rates using Robson's 10-Group classification system in Brazilian private practice

BACKGROUND

Increasing cesarean section (CS) rates are a global concern because they are related to higher maternal and neonatal complication rates and do not provide positive childbirth experiences. In 2019, Brazil ranked second globally, given its overall CS rate of 57%. According to the World Health Organization (WHO), populational CS rates of 10-15% are associated with decreased maternal, neonatal, and infant mortality rates. This study aimed to investigate whether multidisciplinary care following evidence-based protocols associated with a high motivation of both women and professionals for a vaginal birth leads to less overuse of CS in a Brazilian private practice (PP).

METHODS

This cross-sectional study evaluated CS rates by Robson group for women who sought vaginal birth in a private practice in Brazil comparing with Swedish data. Collaborative care of midwives and obstetricians who adopted evidence-based guidelines was offered. CS rates, overall and by Robson group, contribution of each Robson group to the overall CS rate, clinical and nonclinical interventions, vaginal birth, pre-labor CS, and intrapartum CS proportions were estimated. The expected CS rate was calculated using the World Health Organization C-model tool. The analysis used Microsoft Excel and R Studio (version 1.2.1335. 2009-2019).

RESULTS

The PP overall CS rate was 15.1% (95%CI, 13.4-17.1%) versus the 19.8% (95%CI, 14.8-24.7%) rate expected by the WHO C-model tool. The population included 43.7% women in Robson Group 1 (nulliparous, single, cephalic, at term, spontaneous labor), 11.4% in Group 2 (nulliparous, single, cephalic, at term, induced labor or CS before labor), and 14.9% in Group 5 (multiparous women with previous CS), the greatest contributors to higher CS rates (75.4% of them). The Swedish overall CS rate was 17.9% (95%CI, 17.6-18.1%) in a population of 27% women in Robson Group 1, 10.7% in Group 2, and 9.2% in Group 5.

CONCLUSIONS

Multidisciplinary care following evidence-based protocols, associated with high motivation of both women and professionals for vaginal birth, may lead to a significant and safe reduction of CS rates even in contexts such as Brazil, with high medicalization of obstetric care and excess CS.

What is an appropriate caesarean delivery rate for China: a multicentre survey

Objective

To assess the current status of caesarean delivery (CD) in China, propose reference CD rates for China overall, and by regions, investigate the main indications for CDs and identify possible areas for safe reduction.

Design

A multicentre cross‐sectional study.

Setting

A total of 94 hospitals across 23 provinces in China.

Population

A total of 73 977 randomly selected deliveries.

Methods

We used a modified Robson classification to characterise CDs in subgroups and by regions, and the World Health Organization (WHO) C‐Model to calculate reference CD rates.

Main outcome measures

CD rates in China.

Results

In 2015–2016, the overall CD rate in China was 38.9% (95% CI 38.6–39.3%). Considering the obstetric characteristics of the population, the multivariable model‐based reference CD rate was estimated at 28.5% (95% CI 28.3–28.8%). Accordingly, an absolute reduction of 10.4% (or 26.7% relative reduction) may be considered. The CD rate varied substantially by region. Previous CD was the most common indication in all regions, accounting for 38.2% of all CDs, followed by maternal request (9.8%), labour dystocia (8.3%), fetal distress (7.7%) and malpresentation (7.6%). Overall, 12.7% of women had prelabour CDs, contributing to 32.8% of the total CDs.

Conclusions

Nearly 39% of births were delivered by caesarean in China but a reduction of this rate by a quarter may be considered attainable. Repeat CD contributed more than one‐third of the total CDs. Given the large variation in maternal characteristics, region‐specific or even hospital‐specific reference CD rates are needed for precision management of CD.

Tweetable abstract

The caesarean rate in 2015–2016 in China was 38.9%, whereas the reference rate was 28.5%.

The caesarean rate in 2015–2016 in China was 38.9%, whereas the reference rate was 28.5%.

Linked article This article is commented on by M Varner, p. 148 in this issue. To view this mini commentary visit https://doi.org/10.1111/1471-0528.16953.

Cesarean delivery in low- and middle-income countries: A review of quality of care metrics and targets for improvement

Improving quality of care in low-and middle-income countries (LMICs) is a global priority, specifically around maternal and newborn care, where mortality and morbidity remain unacceptably high. Cesarean delivery is the most common procedure in women, thus evaluating quality around the provision of this intervention provides insight into overall quality of care around childbirth. In this review we provide an overview on the quality of care around cesarean delivery using the six domains of quality proposed by the Institute of Medicine: equity, effectiveness, efficiency, safety, timeliness and patient-centered care. We review evidence of potential quality gaps in each of these domains around cesarean delivery in LMICs, discuss opportunities for improvement and provide suggestions on metrics for tracking quality in each of these domains. As cesarean delivery rates increase globally, efforts to ensure quality will be essential to drive continued and sustained improvements in global maternal and newborn outcomes.

External pop-out versus classic technique for delivery of the fetal head during elective cesarean section: A randomized clinical trial

OBJECTIVE

This study aims to compare two techniques (External pop-out versus classic technique) for delivery of the fetal head during elective cesarean section (CS).The potential clinical predictors associated with unintended uterine incision extension during fetal head delivery among women delivered by elective CS were also assessed.

METHODS

A randomized clinical trial conducted at a tertiary University hospital between February 2017 and January 2019. Participants were randomly assigned to the classic head delivery technique (group I) or external Pop-out (EPO) technique (group II). The primary outcome was the incidence of unintended uterine incision extension during elective CS. A logistic regression model was utilized to examine the association between patient's characteristics and the occurrence of unintended uterine incision extension.

RESULTS

Participants in both groups (455 women in each group) had similar demographic characteristics. The EPO group had a significantly lower incidence of uterine incision extension than the classic group (p = 0.006). The operative time was significantly shorter in the EPO group (p = 0.000), which was also significantly easier than the classic technique (p = 0.001). The high body mass index (p = 0.004), previous delivery by CS (p = 0.010), high birth weight (p = 0.001) and the classic technique for head delivery (p = 0.002) were significant predictors for uterine incision tears.

CONCLUSIONS

EPO technique is an easy technique for fetal head delivery during elective CS with a lower risk of uterine incision extension and shorter operative time.

CESAREAN SECTION CLASSIFICATION ACCORDING TO THE ROBSON MODEL, OBSTETRICS UNIT, SAN FELIPE GENERAL HOSPITAL, HONDURAS, APRIL-JUNE, 2017

OBJECTIVE

To classify cesarean sections according to the Robson Model in the obstetrics unit of an intermediate complexity hospital.

METHODS

Descriptive cross-sectional study conducted in the obstetrics unit of the San Felipe General Hospital (HGSF), Tegucigalpa, Honduras, between April and June 2017. Out of 477 clinical records of patients undergoing elective and/ or emergency surgery during the study period, 89 were selected using probabilistic random selection. A descriptive analysis of sociodemographic variables, clinical/obstetric indications, and categories of the Robson model was conducted. Authorization from the institution was obtained.

RESULTS

The proportion of cesarean sections during the study period was 59.8% (477/797; 95% CI:56.3-63.3). Of the cases studied, 48/89 (53.9%) were classified as "no risk pregnancy" (categories 1-4); the most frequent indications in this group were low fetal reserve in 22/48 (22/48*100%) and cephalopelvic disproportion in 16/48 (16/48*100%). In the "risk group" (categories 5-10), in 41/89 (46.1%), indications were cephalopelvic disproportion and breech presentation, (8/41) (8/41*100%), respectively. The main contributors to cesarean section were groups 1 (17/89; 19.1%), 2 (20/89, 22.5%) and 5 (20/89; 22.5%), for a total of 64.1%.

CONCLUSIONS

The Robson model is applicable in our setting and the classification provides information that can be used as a diagnostic and surveillance tool for cesarean sections in a level II institution.

Intentions and influencing factors regarding natural childbirth among urban pregnant women in China, based on the theory of reasoned action and structural equation modeling

Objectives

In the present study, we aimed to analyze the status of natural childbirth and factors influencing delivery behaviors among pregnant women in urban areas based on the theory of reasoned action, to provide a basis for health education on natural childbirth.

Methods

We recruited 658 pregnant women at West China Second University Hospital, Sichuan University. Using a literature review, expert consultation, and self-report questionnaires based on the theory of reasoned action, we investigated delivery behaviors and influencing factors among the included pregnant women. The questionnaires primarily comprised general situations and behavioral intentions regarding natural childbirth among pregnant women. The data were analyzed using IBM SPSS 21.0 software.

Results

According to structural equation modeling, participants’ behavioral intentions regarding natural childbirth were influenced by normative beliefs (standardized regression coefficient 0.402), outcome evaluation (standardized regression coefficient 0.123), and behavioral beliefs (standardized regression coefficient 0.316). Conformity motivation and knowledge about childbirth affected the choice of natural childbirth via normative beliefs (standardized regression coefficients 0.431 and 0.338, respectively).

Conclusions

We found that the behavioral intentions of urban pregnant women with respect to natural childbirth were affected by normative beliefs, outcome evaluations, behavioral beliefs, conformity motivation, and knowledge about childbirth.