Comparative analysis of international cesarean delivery rates using 10-group classification identifies significant variation in spontaneous labor

Application of a specific clinical pathway can affect the choice of trial of labor in patients with a history of cesarean delivery

BACKGROUND

Mode of delivery in women with previous history of cesarean delivery (CD) is highly modifiable by the practices of the delivery unit. Vaginal birth after a cesarean (VBAC) delivery is a safe and preferred alternative in most cases. The aim of this study was to assess the impact of adopting a complex set of measures aimed at the mode of delivery in this group.

METHODS

This was a retrospective observational study comparing two birth cohorts before and after the implementation of a series of quality improvement (QI) interventions. The study cohorts comprised women with a history of cesarean delivery who gave birth in the period before (January 2013 - December 2015) and after (January 2018 - December 2020) the adoption of the QI measures. The measures were focused on singleton term cephalic pregnancies with a low transverse incision in the uterus. Measures included approval of all planned CDs by a senior obstetrician, re-training staff on the use of the FIGO classification for intrapartum fetal cardiotocogram, establishing VBAC management guidelines, encouraging epidural analgesia during trial of labor after cesarean (TOLAC), establishing a labor ward team and introducing a monthly maternity audit.

RESULTS

Term singleton cephalic pregnancies with previous history of CD accounted for 12.55% of all births in the pre-intervention period and 12.01% in the post-intervention period. The frequency of cesarean deliveries decreased from 89.94% in the pre-intervention period to 64.47% in the post-intervention period (p < 0.0001). We observed a significant increase in TOLAC from 13.18 to 42.12% (p<0.0001) and also an increase in successful VBAC from 76.27 to 84.35% (p < 0.0001). All changes occurred without statistically significant change in overall perinatal mortality.

CONCLUSIONS

This study demonstrates the feasibility to safely increase trial of labor and vaginal birth after cesarean delivery by implementing a series of quality improvement interventions and clinical pathway changes.

Errors in the classification of pregnant women according to Robson ten-group classification system

OBJECTIVES

The Robson Ten-Group Classification System (TGCS) is widely used as a classification system for perinatal analyses such as Caesarean section (CS) rates. In Germany, standardised data sets on deliveries are classified by quality assurance institutions using the TGCS. This observational study aims to evaluate potential errors in the TCGS classification of deliveries.

STUDY DESIGN

Manual TGCS classification of all 1370 deliveries in an obstetric unit in 2018 and comparison with semi-automatic TGCS classifications of the quality assurance institution.

RESULTS

In the manual classification, 259 out of 1370 births (18.9 %) were assigned to a different Robson group than in the semi-automatic classification. The proportions of births by Robson group were significantly different in TGCS group 1 (32.2 % vs. 37.6 %, p = 0.0034) and group 2 (18.4 % vs. 14.4 %, p = 0.0053). Concordance between manual and semi-automatic classifications ranged from 59.5 % in group 2 to 100.0 % in groups 6, 7, 8, and 9. The most frequent mismatches were for the parameters "onset of labour" in 184 cases (13.4 %), "parity" in 42 cases (3.1 %) and "previous uterine scars" in 23 cases (1.7 %). In the manual classification, there were significant differences in the CS rate in group 1 (7.9 % vs. 2.5 %, p < 0.0001), group 2 (30.2 % vs. 48.2 %, p < 0.0001), and group 4 (14.1 % vs. 37.4 %, p = 0.0004), compared to the semi-automatic classification.

CONCLUSIONS

Due to incorrect data entry and unclear definitions of criteria, quality assurance data in obstetric databases may contain a relevant proportion of errors, which could influence statistics with TGCS in context of CS rates in international comparisons.

Incidence of Preeclampsia and Cesarean Section Rate According to the Robson Classification

Objectives The objective of this study was to determine the incidence of preeclampsia and associated cesarean section (CS) rate according to the Robson classification. Methods A retrospective cross-sectional study was conducted on a total of 670 women who delivered at a tertiary care hospital in Thailand during January to March 2023. All women were classified into 10 groups according to the Robson classification, and preeclampsia was identified. Overall and group-specific incidence of preeclampsia and CS rate were estimated. Comparison of CS rate was made between those with and without preeclampsia using the Chi-squared test. Relative risks (RR) and corresponding 95% confidence intervals were estimated. Results The majority of women were in group 1 (34%) and group 3 (30.7%). Overall CS rate was 40.6% with highest contribution from group 1, 5, and 10. Incidence of preeclampsia was 9.1%, and the majority were in groups 10 (29.5%) and 1 (23%). Preeclampsia significantly increased the rate of overall CS (RR 1.8, p<0.001). The risk of CS significantly increased in group 1 (RR 1.8, p=0.043), group 3 (RR 3.5, p=0.025), and group 10 (RR 1.9, p=0.006). Preeclampsia accounted for 15.4% of all CS, with the highest contribution in group 2 (37.5%), group 10 (31.1%), group 3 (16.7%), and group 1 (10.8%). Without preeclampsia, the overall CS rate was relatively reduced by 6.9%, with the largest relative reduction in group 10 (14.3%), group 3 (11.5%), group 2 (6.3%), and group 1 (5.2%). Conclusion The incidence of preeclampsia was 9.1%, and preeclampsia significantly increased the rate of overall CS. Without preeclampsia, overall CS rate relatively reduced by 6.9% but did not significantly change the relative contribution of CS according to the Robson classification.

Reproductive outcome after cesarean scar pregnancy

Cesarean scar pregnancy (CSP) rate is rising worldwide, in parallel with the rising rates of cesarean delivery. Multiple therapeutic strategies and a timely diagnosis have led to a successful management in most cases, with many women preserving fertility after treatment. Despite this, still little is known regarding pregnancy outcomes after a CSP. The main adverse outcomes reported after CSP are recurrence of CSP, miscarriage, preterm birth, placenta accreta spectrum (PAS) disorders and uterine rupture. In addition, little is known about the influence of the different treatments on subsequent pregnancy outcomes after a CSP. Being aware of the impact of the different management strategies on the fertility outcomes is highly relevant to counsel pregnant women after a CSP. The aim of this manuscript is to provide an up-to-date review of the reproductive outcomes of women with a history of CSP and of the influence of various treatments on subsequent pregnancy outcomes.

Comparing Cesarean Birth Utilization Between US Hospitals: A Demonstration of the Robson Ten-Group Classification System for Use in Quality Improvement and Benchmarking

BACKGROUND

The World Health Organization-endorsed Robson Ten-Group Classification System (TGCS) is a standard reporting mechanism for cesarean birth, yet this approach is not widely adopted in the United States.

OBJECTIVE

To describe the application and utility of the TGCS to compare hospital-level cesarean births rates, for use in quality improvement and benchmarking.

METHODS

We conducted a descriptive, secondary data analysis of the Consortium on Safe Labor dataset using data from 228 438 women's births, from 2002 to 2008, in 12 sites across the United States. We stratified births into 10 mutually exclusive groups and calculated within-group proportions of group size and cesarean birth rates for between-hospital comparisons of cesarean birth, trial of labor after cesarean (TOLAC), and labor induction utilization.

RESULTS

There is variation in use of cesarean birth, labor induction, and TOLAC across the 12 sites.

CONCLUSION

The TGCS provides a method for between-hospital comparisons, particularly for revealing usage patterns of labor induction, TOLAC, and cesarean birth. Adoption of the TGCS in the United States would provide organizations and quality improvement leaders with an effective benchmarking tool to assist in reducing the use of cesarean birth and increasing the support of TOLAC.

The effect of mindfulness-based counseling on the childbirth experience of primiparous women: a randomized controlled clinical trial

INTRODUCTION

Unpleasant childbirth experience is considered as one of the important factors for cesarean preference. Limited studies have been investigated the impact of psycho-based interventions on the childbirth experience and the most effective counseling approach to promote a pleasant childbirth experience has not been clearly identified.

OBJECTIVE

The present study aimed to evaluate the impact of mindfulness-based counseling on the childbirth experience of primiparous women.

METHODS AND MATERIALS

This randomized controlled clinical trial was conducted on 64 primiparous with gestational age of 32 to 34 weeks referred to the perinatology clinic of Al-Zahra and Taleghani educational-treatment hospital, affiliated to Tabriz University of Medical sciences, Iran. Participants were randomly assigned into the intervention and control groups. The intervention group received eight mindfulness-based counseling sessions. The intensity of childbirth pain with VAS (Visual Analog Scale) in the active phase of labor at 8 cm dilatation and the childbirth experience questionnaire were completed by interview after childbirth. Independent t-test and ANCOVA were used to compare the outcomes between the two groups.

RESULTS

After controlling the effect of confounding variables, the mean score of childbirth experience in the intervention group was significantly higher than that in control group [Mean Difference (MD): 1.79, 95% CI: 2.52 to 1.07, P < 0.01]. The mean score of labor pain in the intervention group was significantly lower than that in the control group after controlling the effect of baseline score and confounding variables [MD: -2.21, 95% CL: -3.35 to -1.10, P < 0.001].

CONCLUSION

The findings indicated that providing mindfulness-based counseling improves the childbirth experience and reduces labor pain during childbirth. However, further randomized clinical trials are needed before making a definitive conclusion.

TRIAL REGISTRATION

Iranian Registry of Clinical Trials (IRCT): IRCT20171007036615N9. Date of registration: 16/03/2022, 25/12/1400.

Implementation of the Robson Classification in Greece: A Retrospective Cross-Sectional Study

Cesarean sections have become the most commonly performed operations around the world. The World Health Organization recommended the use of the Robson classification system as a universal standard to establish a joint control system in healthcare facilities. The aim of this study was to implement the Robson classification for the first time in Greece to identify trends in cesarean births and examine the groups of women who are the main contributors to the increasing rates. Moreover, the indicators for cesarean sections will be evaluated as per the Robson classification. In the sample analysis, we included the records of 8572 women giving birth in one private health facility in Greece. A total of 8572 women gave birth during the study period, of which 5224 (60.9%) were cesarean section births and 3348 (39.1%) were vaginal births. In our study, according to the Robson classification, the largest contributors to the overall CS rate were as follows: (a) nulliparous women with a single cephalic term pregnancy, who were either labor induced or delivered by cesarean section before labor-Group 2 (34.6%); (b) multiparous women with a single cephalic term pregnancy and at least one previous cesarean section-Group 5 (30.7%); (c) women with a single cephalic preterm pregnancy-Group 10 (11.7%); (d) women with multiple pregnancies-Group 8 (7.0%). Our study is expected to assist policymakers in Greece in planning further interventions for each subgroup of women in order to reduce the overall CS rate and unnecessary CSs.

Is gestational age at term a risk factor for ongoing pregnancies in nulliparous women: A prospective cohort study

BACKGROUND

The results of American observational studies and 1 large, randomized trial show that elective induction of labor among nulliparous women can reduce cesarean delivery rates and suggest that gestational age at delivery may be a risk factor for cesarean delivery in pregnancies managed expectantly. However, data on the risk of cesarean delivery at term in ongoing pregnancies are sparse, especially in high-income countries, and further information is needed to explore the external validity of these previous studies.

OBJECTIVE

This study aimed to evaluate the risk of cesarean delivery for each gestational week of ongoing pregnancy in nulliparous women with a singleton fetus in the cephalic presentation at term in a French population.

STUDY DESIGN

This retrospective study was conducted in a perinatal network of 10 maternity units from January 1, 2016, to December 31, 2017, and included all nulliparous women with a singleton fetus in the cephalic presentation who gave birth at term (≥37 0/7 weeks of gestation). From the start of term (37 completed weeks) and at the start of each subsequent week of completed gestation (each week + 0 days), ongoing pregnancy was defined as that of a woman who was still pregnant and who gave birth at any time after that date. For each week of gestation for these ongoing pregnancies, the cesarean delivery rate was defined as the number of cesarean deliveries performed in each ongoing pregnancy group divided by the number of women in this group. Separate models for each week of gestation, adjusted by maternal characteristics and hospital status, were used to compare the cesarean delivery risk between ongoing pregnancies and those delivered the preceding week. The same methods were applied to subgroups defined according to the mode of labor onset. Odds ratios were calculated after adjusting for maternal age and educational level, presence of severe preeclampsia, and maternity unit status.

RESULTS

The study included 11,308 nulliparous women, 2544 (22.5%) of whom had a cesarean delivery. These rates remained stable for ongoing pregnancies at 37 0/7, 38 0/7, and 39 0/7 weeks of gestation; the rates were 22.5% (95% confidence interval, 21.7-23.2), 22.6% (95% confidence interval, 21.8-23.3); and 22.7% (95% confidence interval, 21.9-23.6), respectively. The risk of cesarean delivery started to increase in ongoing pregnancies at 40 0/7 weeks of gestation (24.3%; 95% confidence interval, 23.1-25.4) and especially at 41 0/7 weeks of gestation (30.7%; 95% confidence interval, 28.9-32.5). Similar trends were also shown for all modes of labor onset and in every maternity unit. In univariate and multivariate analyses, ongoing pregnancy at or beyond 40 0/7 weeks of gestation was associated with a higher risk of cesarean delivery than pregnancy delivered the previous week: 24.3% of ongoing pregnancies at 40 0/7 weeks of gestation vs 19.9% of deliveries between 39 0/7 weeks of gestation and 39 6/7 weeks of gestation. The odds ratios were 1.28 (95% confidence interval, 1.15-1.44) or 30.4% of ongoing pregnancies at 41 0/7 weeks of gestation vs 1.73 (95% confidence interval, 1.51-1.96) or 19.6% of deliveries between 40 0/7 weeks of gestation and 40 6/7 weeks of gestation.

CONCLUSION

Cesarean delivery rates increased starting at 40 0/7 weeks of gestation in ongoing pregnancies regardless of the mode of labor onset.

Guideline No. 432a: Cervical Ripening and Induction of Labour - General Information

OBJECTIVE

This guideline presents evidence and recommendations for cervical ripening and induction of labour. It aims to provide information to birth attendants and pregnant individuals on optimal perinatal care while avoiding unnecessary obstetrical intervention.

TARGET POPULATION

All pregnant patients.

BENEFITS, HARMS, AND COSTS

Consistent interprofessional use of the guideline, appropriate equipment, and trained professional staff enhance safe intrapartum care. Pregnant individuals and their support person(s) should be informed of the benefits and risks of induction of labour.

EVIDENCE

Literature published to March 2022 was reviewed. PubMed, CINAHL, and the Cochrane Library were used to search for systematic reviews, randomized controlled trials, and observational studies on cervical ripening and induction of labour. Grey (unpublished) literature was identified by searching the websites of health technology assessment and health technology related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies.

VALIDATION METHODS

The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See online Appendix A (Tables A1 for definitions and A2 for interpretations of strong and conditional [weak] recommendations).

INTENDED AUDIENCE

All providers of obstetrical care.

RECOMMANDATIONS

Directive clinique no 432a : Maturation cervicale et déclenchement artificiel du travail - Information générale

OBJECTIF

Présenter des données probantes et des recommandations sur la maturation cervicale et le déclenchement artificiel du travail. Fournir de l'information aux professionnels accoucheurs et aux personnes enceintes sur les soins périnataux optimaux et la prévention des interventions obstétricales inutiles.

POPULATION CIBLE

Toutes les patientes enceintes. BéNéFICES, RISQUES ET COûTS: La mise en application interprofessionnelle et cohérente de la présente directive, l'équipement adéquat et le personnel compétent améliorent la sécurité des soins per partum. Les personnes enceintes et leurs personnes de soutien doivent être informées des risques et bénéfices du déclenchement artificiel du travail. DONNéES PROBANTES: La littérature publiée jusqu'en mars 2022 a été passée en revue. Une recherche a été effectuée dans les bases de données PubMed, CINAHL et Cochrane Library pour répertorier des revues systématiques, des essais cliniques randomisés et des études observationnelles sur la maturation cervicale et le déclenchement artificiel du travail. La littérature grise (non publiée) a été obtenue à l'aide de recherches menées dans des sites Web d'organismes s'intéressant à l'évaluation des technologies dans le domaine de la santé et d'organismes connexes, dans des collections de directives cliniques, des registres d'essais cliniques et des sites Web de sociétés de spécialité médicale nationales et internationales. MéTHODES DE VALIDATION: Les auteurs ont évalué la qualité des données probantes et la force des recommandations en utilisant le cadre méthodologique GRADE (Grading of Recommendations Assessment, Development and Evaluation). Voir l'annexe A en ligne (tableau A1 pour les définitions et tableau A2 pour l'interprétation des recommandations fortes et conditionnelles [faibles]). PROFESSIONNELS CONCERNéS: Tous les fournisseurs de soins obstétricaux.

RECOMMANDATIONS

Disquiet concerning cesarean birth

Cesarean birth has increased substantially in many parts of the world over recent decades and concerns have been raised about the propriety of this change in obstetric practice. Sometimes, a cesarean is necessary to preserve fetal and maternal health. But in balancing the risks of surgical intervention the implicit assumption has been that cesarean birth is an equivalent alternative to vaginal birth from the standpoint of the immediate and long-term health of the fetus and neonate. Increasingly, we realize this is not necessarily so. Delivery mode per se may influence short-term and abiding problems with homeostasis in offspring, quite independent of the indications for the delivery and other potentially confounding factors. The probability of developing various disorders, including respiratory compromise, obesity, immune dysfunction, and neurobehavioral disorders has been shown in some studies to be higher among individuals born by cesarean. Moreover, many of these adverse effects are not confined to the neonatal period and may develop over many years. Although the associations between delivery mode and long-term health are persuasive, their pathogenesis and causality remain uncertain. Full exploration and a clear understanding of these relationships is of great importance to the health of offspring.

Achieving an appropriate cesarean birth (CB) rate and analyzing the changes using the Robson Ten-Group Classification System (TGCS): Lessons from a Tertiary Care Hospital in Italy

BACKGROUND

To describe the interventions that were implemented at a Tertiary University Hospital and how they affected the rate of cesarean birth (CB) and main obstetrics and neonatal outcomes.

STUDY DESIGN

An analysis of the contemporaneously collected data from all deliveries that occurred from 2014 to 2018. Major obstetric and neonatal outcomes were analyzed and grouped according to the Ten-Group Classification System (TGCS).

RESULTS

A significant decrease in CB rates, from 28.4% to 23.0% (P < 0.001), was found over the study period. Although the relative sizes of both nulliparous (groups 1 + 2) and multiparous (groups 3 + 4) women remained stable over the study period, a significantly higher incidence of CB was reported in 2014 for both groups, compared with 2018 (2.6% vs. 13.0%, P < 0.001 for nulliparous women and 7.5% vs. 3.3%, P < 0.001 for multiparous women). In contrast, the relative size of Group 5 was significantly lower in 2014 than in 2018 (9.9% vs. 11.5%, P = 0.003), but a 13.3% reduction in CB was also reported for this group. No significant differences were noted in the occurrence of major obstetrics and neonatal outcomes that were reported.

CONCLUSIONS

A reduction in CB rate may be safely achieved through implementing a multifaceted strategy.

Cesarean section rate changes after audit and feedback with the Ten Group Classification System in a French perinatal network: A retrospective pre-post study

INTRODUCTION

The rise in the number of cesarean sections (CS) is a major health public problem which concerns nearly all countries. It is suggested that the Ten Group Classification System be adapted to a procedure of audit/feedback cycles, which could have an effect on CS practice. Therefore, we aimed to study changes in CS rates between maternity wards in a perinatal network after implementation of the Ten Group Classification System in an audit with feedback.

MATERIAL AND METHODS

This was a retrospective pre-post study of all births from 1 January 2012 to 31 December 2018, in a French perinatal network of 10 maternity wards in the Yvelines district of France. All live births occurring at a gestational age ≥24 weeks in the network were included. During the pre-period (1 January 2012 to 31 December 2014), the audit and feedback provided only overall CS rates. During the post-period (1 January 2015 to 31 December 2018), CS rates for each Robson Ten Group Classification System group were provided. Regression models, adjusted for maternal characteristics and maternity ward, were used to compare CS rates globally and for each group of the system. Variability of CS rates between maternity wards was analyzed using the coefficients of variation.

RESULTS

There were 51 082 women who delivered during the pre-period and 63 964 during the post-period. The overall CS rate did not decrease (24.5% during the pre-period vs 25.1% during the post-period). There were no significant differences in CS rates for any group of the Ten Group Classification System after adjustment for maternity, maternal age and sociodemographic characteristics, nor did audit implementation decrease CS rate variability between maternity wards or within groups of the system.

CONCLUSIONS

Implementation of an audit-and-feedback cycle using the Ten Group Classification System did not decrease either CS rates or variability between maternity wards.

Predicting the Relation between Biopsychosocial Factors and Type of Childbirth using the Decision Tree Method: A Cohort Study

Background

With the growing rate of cesarean sections, rising morbidity and mortality thereafter is an important health issue. Predictive models can identify individuals with a higher probability of cesarean section, and help them make better decisions. This study aimed to investigate the biopsychosocial factors associated with the method of childbirth and designed a predictive model using the decision tree C4.5 algorithm.

Methods

In this cohort study, the sample included 170 pregnant women in the third trimester of pregnancy referring to Shahroud Health Care Centers (Semnan, Iran), from 2018 to 2019. Blood samples were taken from mothers to measure the estrogen hormone at baseline. Birth information was recorded at the follow-up time per 30-42 days postpartum. Chi square, independent samples t test, and Mann-Whitney were used for comparisons between the two groups. Modeling was performed with the help of MATLAB software and C4.5 decision tree algorithm using input variables and target variable (childbirth method). The data were divided into training and testing datasets using the 70-30% method. In both stages, sensitivity, specificity, and accuracy were evaluated by the decision tree algorithm.

Results

Previous method of childbirth, maternal body mass index at childbirth, maternal age, and estrogen were the most significant factors predicting the childbirth method. The decision tree model's sensitivity, specificity, and accuracy were 85.48%, 94.34%, and 89.57% in the training stage, and 82.35%, 83.87%, and 83.33% in the testing stage, respectively.

Conclusion

The decision tree model was designed with high accuracy successfully predicted the method of childbirth. By recognizing the contributing factors, policymakers can take preventive action.It should be noted that this article was published in preprint form on the website of research square (https://www.researchsquare.com/article/rs-34770/v1).

Analysis of cesarean section rates in two German hospitals applying the 10-Group Classification System

OBJECTIVES

In Germany, cesarean section (CS) rates more than doubled within the past two decades. For analysis, auditing and inter-hospital comparison, the 10-Group Classification System (TGCS) is recommended. We used the TGCS to analyze CS rates in two German hospitals of different levels of care.

METHODS

From October 2017 to September 2018, data were prospectively collected. Unit A is a level three university hospital, unit B a level one district hospital. The German birth registry was used for comparison with national data. We performed two-sample Z tests and bootstrapping to compare aggregated (unit A + B) with national data and unit A with unit B.

RESULTS

In both datasets (national data and aggregated data unit A + B), Robson group (RG) 5 was the largest contributor to the overall CS rate. Compared to national data, group sizes in RG 1 and 3 were significantly smaller in the units under investigation, RG 8 and 10 significantly larger. Total CS rates between the two units differed (40.7 vs. 28.4%, p<0.001). The CS rate in RG 5 and RG 10 was different (p<0.01 for both). The most relative frequent RG in both units consisted of group 5, followed by group 10 and 2a.

CONCLUSIONS

The analysis allowed us to explain different CS rates with differences in the study population and with differences in the clinical practice. These results serve as a starting point for audits, inter-hospital comparisons and for interventions aiming to reduce CS rates.

Variation between hospital caesarean delivery rates when Robson's classification is considered: An observational study from a French perinatal network

INTRODUCTION

WHO has recommended using Robson's Ten Group Classification System (TGCS) to monitor and analyze CD rates. Its failure to take some maternal and organizational factors into account, however, could limit the interpretation of CD rate comparisons, because it may contribute to variations in hospital CD rates.

OBJECTIVE

To study the contribution of maternal socioeconomic and clinical characteristics and hospital organizational factors to the variation in CD rates when using Robson's ten-group classification system for CD rate comparisons.

METHODS

This prospective, observational, population-based study included all deliveries at a gestational age > 24 weeks at the 10 hospitals of the French MYPA perinatal network in the Paris area. CD rates were calculated for each TGCS group in each hospital. Interhospital variations in these rates were investigated with hierarchical logistic regression models to quantify the variation explained by differences in patient and hospital characteristics when the TGCS is considered. Variations in CD rates between hospitals were estimated with median odds ratios (MOR) to express interhospital variance on the standard odds ratio scale. The percentage of variation explained by TGCS and maternal and hospital characteristics was also calculated.

RESULTS

The global CD rate was 24.0% (interhospital range: 17-32%). CD rates within each TGCS group differed significantly between hospitals (P<0.001). CD was significantly associated with maternal age (>40 years), severe preeclampsia, and two organizational factors: hospital status (private maternities) and the deliveries per staff member per 24 hours. The MOR in the empty model was 1.27 and did not change after taking the TGCS into account. Adding maternal characteristics and hospital organizational factors lowered the MOR to 1.14 and reduced the variation between hospital CD rates by 70%.

CONCLUSION

Maternal characteristics and hospital factors are needed to address variation in CD rates among the TGCS groups. Therefore, comparisons of these rates that do not consider these factors should be interpreted carefully.

Examining Cesarean Delivery Rates by Race: a Population-Based Analysis Using the Robson Ten-Group Classification System

The Robson Ten-Group Classification System is widely considered to be the gold standard for comparing cesarean section (CS) delivery rates, despite limited adoption in the United States (US). When reporting overall CS rates, Blacks and other minorities are typically reported to have high CS rates but comparing overall CS rates may be misleading as CS may be more common in some higher risk populations. Improved understanding of how CS rates differ by race among standardized groups could highlight differences in care and areas for improvement. The current study examines racial differences in cesarean section delivery rates using the Robson Ten-Group Classification System in a nationwide sample. Data from US vital statistics live birth certificates were used to identify 3,906,088 births which were each classified into one of the ten groups based on five obstetric characteristics identifiable on presentation for delivery including parity, onset of labor, gestational age, fetal presentation, and number of fetuses. Results indicated that Black and Asian mothers had the highest CS rates in groups 1-4 which all contain single, cephalic pregnancies at term with no prior CS and are only differentiated by parity and onset of labor. Black mothers also had the lowest CS rates for groups 6 and 7, containing women with nulliparous and multiparous breech births. Black and Asian mothers show differences in CS rates among groups that could indicate lack of appropriate care. Efforts should be made to prevent unnecessary primary CS among low-risk mothers.

Evaluation of cesarean delivery rates in different levels of hospitals in Jiangsu Province, China, using the 10-Group classification system

OBJECTIVE

To compare cesarean delivery (CD) rates in referral and non-referral hospitals in Maternal Safety Collaboration in Jiangsu province, China.

METHODS

Sixteen participants (4 referral hospitals, 12 non-referral hospitals) from Drum Tower Hospital Collaboration for Maternal Safety reported CD rates in 2019 using ten-group classification system and maternal/neonatal morbidity and mortality.

RESULTS

A total of 22,676 CDs were performed among 52,499 deliveries and the average CD rate was 43.2% (range 34.8-69.6%). CD rate in non-referral hospitals (44.7%) was significantly higher than it was in referral hospitals (40.4%, p < .001). Term singleton cephalic nulliparous women with spontaneous labor (Group 1) or induced labor (Group 2a) had higher CD rates if they were cared in non-referral hospitals compared with those in referral hospitals (Group 1: 11.8% vs. 4.4%, p < .001; Group 2a: 29.1% vs. 21.3%, p < .001). In non-referral hospitals, CD rate in Group 5 and the proportion of Group 5 to the overall population were also significantly higher than those in referral hospitals (98.5% vs. 92.5%, p < .001; and 21.0% vs. 14.5%, p < .001).

CONCLUSION

To decrease the CD rate, we need to take efforts in decreasing unnecessary operations for term singleton cephalic nulliparous women and increasing the rate of trial of labor after CD.

Feasibility of Conducting a Trial Assessing Benefits and Risks of Planned Caesarean Section Versus Planned Vaginal Birth: A Cross-Sectional Study

INTRODUCTION

Though interest is growing for trials comparing planned delivery mode (vaginal delivery [VD]; cesarean section [CS]) in low-risk nulliparous women, appropriate study design is unclear. Our objective was to assess feasibility of three designs (preference trial [PCT], randomized controlled trial [RCT], partially randomized patient preference trial [PRPPT]) for a trial comparing planned delivery mode in low-risk women.

METHODS

A cross-sectional survey of low-risk, nulliparous pregnant women (N = 416) and healthcare providers (N = 168) providing prenatal care and/or labor/delivery services was conducted in Argentina (2 public, 2 private hospitals). Proportion of pregnant women and providers willing to participate in each design and reasons for not participating were determined.

RESULTS

Few women (< 15%) or professionals (33.3%) would participate in an RCT, though more would participate in PCTs (88% women; 65.9% professionals) or PRPPTs (44.4% public, 63.4% private sector women; 44.0% professionals). However, most women would choose vaginal delivery in the PCT and PRPPT (> 85%). Believing randomization unacceptable (RCT, PRPPT) and desiring choice of delivery mode (RCT) were women's reasons for not participating. For providers, commonly cited reasons for not participating included unacceptability of performing CS without medical indication, difficulty obtaining informed consent, discomfort enrolling patients (all designs), and violating women's right to choose (RCT).

CONCLUSIONS FOR PRACTICE

Important limitations were found for each trial design evaluated. The necessity of stronger evidence regarding delivery mode in low-risk women suggests consideration of additional designs, such as a rigorously designed cohort study or an RCT within an obstetric population with equivocal CS indications.

Cesarean section and childhood infections: Causality for concern?

In this Perspective, Gordon Smith discusses the findings of Miller et al, and the balance of risks and benefits associated with different modes of delivery.

A 10 year comparative study of caesarean deliveries using the Robson 10 group classification system in a university hospital in Austria

OBJECTIVE

The Robson ten group classification system is used as a global standard for assessing, monitoring and comparing caesarean delivery (CD) rates within and between maternity services. Our objective was to compare the changes of CD rates at our institution between the years 2008-2010 and 2017-2019 using the Robson ten group classification system.

STUDY DESIGN

Data was collected retrospectively and all women were classified using the obstetric concepts and parameters described in the Robson ten group classification system.

RESULTS

During 2008-2010 7,832 deliveries were performed, increasing to 9,490 in 2017-2019. The CD rate also increased from 29.1% to 32.2% (p<.05) during this 10 year period. In both observed periods group 5 (single cephalic multiparous women at term with a previous CD) was the largest contributor to the overall CD rate accounting for 20.2% of all CD during 2008-2010 and increasing to 26.9% in 2017-2019 (p<.001). The overall size of group 5 also increased from 8.3% to 11.6% (p<.001). Furthermore, an increase in CD rate in group 7 (multiparous women with a single breech pregnancy, including women with a uterine scar) from 92.9% to 98.2% (p = .752) could be observed. In group 8 (women with multiple pregnancies, including women with a uterine scar) a slight shift towards vaginal delivery (VD) can be reported with CD rates decreasing from 82% to 79.2% (p = .784). There was no observed difference with CD rates in group 1 although the group size decreased from 29.4% in 2008-2010 to 24.2% in 2017-2019 (p<.001). The CD rate in group 10 experienced a slight elevation, in 2008-2010 46.2% were delivered per CD and in 2017-2019 48.8% (p = .553). The overall size of group 10 decreased, contributing 8.9% in 2008-2010 and 8% in 2017-2019 (p<.05) to the overall birthrate.

CONCLUSION

The biggest contributors to the CD rate in our hospital remain multiparous women at term with a previous CD. The CD rates, as well as the overall size of this group, keep rising, resulting in a need to establish more effective ways to motivate women with one previous CD towards vaginal birth after caesarean delivery (VBAC). Furthermore, the CD rate in preterm deliveries is increasing and approaching 50%. This illustrates the need to discuss whether CD is the appropriate mode of delivery in half of the preterm infants.

Cesarean-section Rates in Brazil from 2014 to 2016: Cross-sectional Analysis Using the Robson Classification

OBJECTIVE

 To obtain cesarean-section (CS) rates according to the Robson Group Classification in five different regions of Brazil.

METHODS

 A descriptive epidemiological study using data from secondary birth records from the Computer Science Department of the Brazilian Unified Health System (Datasus, in Portuguese) between January 1st, 2014, and December 31st, 2016, including all live births in Brazil.

RESULTS

 The overall rate of CS was of 56%. The sample was divided into 11 groups, and vaginal births were more frequent in groups 1 (53.6%), 3 (80.0%) and 4 (55.1%). The highest CS rates were found in groups 5 (85.7%), 6 (89.5%), 7 (85.2%) and 9 (97.0%). The overall CS rate per region varied from 46.2% in the North to 62.1% in the Midwest. Group 5 was the largest obstetric population in the South, Southeast and Midwest, and group 3 was the largest in the North and Northeast. Group 5 contributed the most to the overall CS rate, accounting for 30.8% of CSs.

CONCLUSION

 Over half of the births in Brazil were cesarean sections. The Midwest had the highest CS rates, while the North had the lowest. The largest obstetric population in the North and in the Northeast was composed of women in group 3, while in the South, Southeast and Midwest it was group 5. Among all regions, the largest contribution to the overall CS rate was from group 5.

Cesarean Section Rate Analysis in a Tertiary Hospital in Portugal According to Robson Ten Group Classification System

OBJECTIVE

 The Robson 10 group classification system (RTGCS) is a reproducible, clinically relevant and prospective classification system proposed by the World Health Organization (WHO) as a global standard for assessing, monitoring and comparing cesarean section (CS) rates. The purpose of the present study is to analyze CS rates according to the RTGCS over a 3-year period and to identify the main contributors to this rate.

METHODS

 We reviewed data regarding deliveries performed from 2014 up to 2016 in a tertiary hospital in Portugal, and classified all women according to the RTGCS. We analyzed the CS rate in each group.

RESULTS

 We included data from 6,369 deliveries. Groups 1 (n = 1,703), 2 (n = 1,229) and 3 (n = 1,382) represented 67.7% of the obstetric population. The global CS rate was 25% (n = 1,594). Groups 1, 2, 5 and 10 were responsible for 74.2% of global CS deliveries.

CONCLUSION

 As expected, Groups 1, 2, 5 and 10 were the greatest contributors to the overall CS rate. An attempt to increase the number of vaginal deliveries in these groups, especially in Groups 2 and 5, might contribute to the reduction of the CS rate.

The impact of cesarean section on neonatal outcomes at a university-based tertiary hospital in Jordan

Background

Over the past two decades, there has been a steady rise in the rate of Cesarean section delivery globally. As a result, short-term and long-term maternal and neonatal complications are rising. The objective of this study is to determine the rate and indications for Cesarean section at King Abdullah University Hospital (KAUH) in Jordan and to assess the resulting neonatal outcomes.

Methods

A retrospective chart review was conducted for all women and neonates delivered by Cesarean section during the period January 2016 to July 2017 at KAUH tertiary academic center. Collected data include demographic characteristics, indication for delivery, and neonatal outcomes such as NICU admission, respiratory complications, sepsis, mortality, and length of hospitalization.

Results

Two thousand five hundred ninety-five Cesarean section deliveries were performed over 18 months representing a rate of 50.5% of all deliveries. Sixty percent were scheduled procedures. Seventy-two percent were performed at full term gestation. The most common indication was previously scarred uterus (42.8%) followed by fetal distress (15.5%). The rate of admission to the neonatal ICU was 30% (800/2595). After multilogistic conditional regression analysis, the factors associated with increased risk of neonatal ICU admission were found to include grandmultiparity (Adjusted OR 1.46), gestational diabetes (Adjusted OR 1.92), maternal employment (Adjusted OR 1.84), prolonged rupture of membranes (Adjusted OR 5), fetal distress (Adjusted OR 1.84), prematurity (Adjusted OR 43.78), low birth weight (Adjusted OR 42), high order multiple gestation (Adjusted OR 9.58) and low 5-min APGAR score (Adjusted OR 10). Among the babies electively delivered at early term (37–38.6 weeks), 16% were admitted to the NICU for a median length of stay of 4 days (IQR 2, 8). The most common diagnoses for admitted term neonates were transient tachypnea of newborns and respiratory distress syndrome.

Conclusions

CS deliveries account for more than half the number of deliveries at our institution and almost one third of the delivered babies are admitted to the NICU. Together with the resulting maternal and neonatal consequences, this carries a major burden on the newborns, health care facilities, and involved families. Local strategies and policies should be established and implemented to improve the outcome of births.

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.

Women's satisfaction with the birthing experience in relation to duration of labour, obstetric interventions and mode of birth

OBJECTIVE

To study the influence of the duration of labour on women's satisfaction with their birthing experience.

STUDY DESIGN

All labours and births during a four-year period at a secondary level Hospital were included in a continuous audit of events and outcomes based on the Ten Group Classification System (TGCS). The women scored their overall satisfaction with their birth experience on an ordinal Visual Analog Scale.

RESULTS

1780 nulliparous women with a cephalic fetus at term and spontaneous onset of labour in TGCS Group 1 gave birth during the study period. 1716 had complete data on duration of labour and, of these, 1380 (80,4 %) rated their satisfaction with their birthing experience. Satisfaction with the birthing experience was significantly related to mode of birth, oxytocin augmentation, epidural anaesthesia and to duration of labour. Duration of labour and mode of birth had independent significant statistical effect on the satisfaction with the birthing experience.

CONCLUSION

Although various aspects of labour management are associated with a negative birth experience, the effect of prolonged labour is independently significant and measures taken to avoid prolonged labour could result in a net benefit to the woman's satisfaction.

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.

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.

Evaluation of cesarean delivery rates at three university hospital labor units using the Robson classification system

OBJECTIVE

To analyze the frequency of cesarean delivery using the Robson 10-group classification.

METHODS

A multicenter retrospective cohort study was conducted at three university hospital labor units in the Slovak Republic. The medical records of all women who gave birth at these centers from January 1 to December 31, 2017, were assessed.

RESULTS

In all, 1437 of 3361 (42.8%), 729 of 2795 (26.1%), and 303 of 2080 (14.6%) births recorded at the three centers during the current study period were by cesarean delivery. Among the nulliparous term singleton vertex deliveries (Robson group 1 and 2), the frequency of cesarean delivery at the three centers was 613 of 1653 (37.1%), 278 of 1389 (20.0%), and 91 of 898 (10.1%). Among term multiparas with one fetus in a cephalic position and at least one previous cesarean delivery (Robson group 5), the frequency of cesarean delivery at the three centers was 405 of 418 (96.9%), 261 of 343 (76.1%), and 55 of 115 (47.8%).

CONCLUSION

Analysis of the frequency of cesarean delivery by Robson classification could help to identify possibilities for safely decreasing cesarean delivery rates in the clinic. Robson groups 1, 2, and 5 were the most modifiable groups.

The continuous audit of events and outcomes of labour and birth using the Ten Group Classification System and its role in quality improvement

OBJECTIVE

The knowledge of a labour and birth unit's rates of events and outcomes is essential to design any quality improvement initiative. It is in the same way important to have a system to analyse results of the ongoing changes within the unit. The Ten Group Classification System is the framework for doing this in a systematic and clinically relevant way. We aimed to use this classification system as a quality improvement tool.

STUDY DESIGN

All labours and births during four years at a secondary level Hospital were included in a continuous analysis and of events and outcomes based on the Ten Group Classification System. From the results of the audit, policies and guidelines were designed and updated to improve outcomes.

RESULTS

The normal vaginal birth rate in Group 1 increased during the four-year-period and the Caesarean Section rate in Group 2 A dropped after the introduction of a new induction method. The overall Caesarean Section rate decreased. The experience of giving birth improved in Groups 1, 2 A and 3.

CONCLUSION

The use of a continuous audit of events and outcomes based on a clinically significant classification for all women makes it possible to improve quality. Other labour and birth units are encouraged to collect and present data in a way that allows comparisons between units and over time.

Caesarean section in Palestine using the Robson Ten Group Classification System: a population-based birth cohort study

OBJECTIVE

To analyse the current situation of caesarean section in Palestine using the Robson Ten Group Classification System (TGCS).

DESIGN

A population-based birth cohort study.

SETTING

Obstetrical departments in three governmental hospitals in Gaza.

PARTICIPANTS

All women (18 908) who gave birth between 1 January 2016 and 30 April 2017.

METHODS

The contributions of each group to the study population and to the overall rate of caesarean section were calculated, as well as the rate of caesarean section in each TGCS group. Differences in proportions between study hospitals were assessed by χ² test.

MAIN OUTCOME MEASURES

The main outcome was the contributions of each group to the overall caesarean section rate.

RESULTS

The overall rate of caesarean section was 22.9% (4337 of 18 908), ranging from 20.6% in hospital 1 to 24.6% in hospital 3. The largest contributors to the overall caesarean section rate were multiparous women with single cephalic full-term pregnancy who had undergone at least one caesarean section (group 5, 42.6%), women with multiple pregnancies (group 8, 11.6%) and those with single cephalic preterm labour (group 10, 8.1%). Statistically significant differences in caesarean section rates between the study hospitals were observed in group 1 (nulliparous women with single cephalic full-term pregnancy and spontaneous labour), group 4 (multiparous with single cephalic full-term pregnancy with induced labour or prelabour caesarean section), group 5 (multiparous with single cephalic full-term pregnancy with previous caesarean section) and in group 7 (multiparous with breech presentation).

CONCLUSION

Women in groups 5, 8 and 10 were the largest contributors to the overall caesarean section rate in the study hospitals. Efforts to reduce the differences in obstetrical care between hospitals need to be directed towards increasing the proportion of vaginal births after caesarean section and by reducing primary caesarean section in multiple pregnancies and preterm labour.

Primary cesarean delivery rate: Potential impact of a checklist

BACKGROUND

Cesarean section is the most common surgical procedure performed in developed countries. Its incidence is increasing to a worrisome extent. The 2003 French National Perinatal Survey showed that the inflation in the overall cesarean rate was mainly due to an increase in the first cesarean delivery rate.

OBJECTIVE

To evaluate a new tool: a checklist that intent to decrease the first cesarean delivery rate.

STUDY DESIGN

Retrospective, observational, multi-center study. A new tool, a "First cesarean delivery" checklist was built according American and French guidelines. Women with full-term of pregnancy, nulliparous or multiparous with a first caesarean delivery including arrest of labor, breech presentation or suspected fetal macrosomia were included. The checklist was applied. Potentially preventable cesareans were analyzed.

RESULTS

Among 571 first cesarean section, 178 were eligible to check list application. 147 charts were analyzed in the study. 11.9% of first cesarean deliveries performed were potentially avoidable after applying the checklist. This represented 6.6% of all cesareans.

CONCLUSION

The checklist based on the recall of good practices could be an interesting tool to decrease the first cesarean rate.

Cesarean delivery in the United States 2005 through 2014: a population-based analysis using the Robson 10-Group Classification System

BACKGROUND

Cesarean delivery has increased steadily in the United States over recent decades with significant downstream health consequences. The World Health Organization has endorsed the Robson 10-Group Classification System as a global standard to facilitate analysis and comparison of cesarean delivery rates.

OBJECTIVE

Our objective was to apply the Robson 10-Group Classification System to a nationwide cohort in the United States over a 10-year period.

STUDY DESIGN

This population-based analysis applied the Robson 10-Group Classification System to all births in the United States from 2005 through 2014, recorded in the 2003 revised birth certificate format. Over the study 10-year period, 27,044,217 deliveries met inclusion criteria. Five parameters (parity including previous cesarean, gestational age, labor onset, fetal presentation, and plurality), identifiable on presentation for delivery, were used to classify all women included into 1 of 10 groups.

RESULTS

The overall cesarean rate was 31.6%. Group-3 births (singleton, term, cephalic multiparas in spontaneous labor) were most common, while group-5 births (those with a previous cesarean) accounted for the most cesarean deliveries increasing from 27% of all cesareans in 2005 through 2006 to >34% in 2013 through 2014. Breech pregnancies (groups 6 and 7) had cesarean rates >90%. Primiparous and multiparous women who had a prelabor cesarean (groups 2b and 4b) accounted for over one quarter of all cesarean deliveries.

CONCLUSION

Women with a previous cesarean delivery represent an increasing proportion of cesarean deliveries. Use of the Robson criteria allows standardized comparisons of data and identifies clinical scenarios driving changes in cesarean rates. Hospitals and health organizations can use the Robson 10-Group Classification System to evaluate quality and processes associated with cesarean delivery.

Mode of delivery after a previous cesarean birth, and associated maternal and neonatal morbidity

BACKGROUND

The mode of delivery for women with a previous cesarean delivery remains contentious. We conducted a study comparing maternal and infant outcomes after attempted vaginal birth after cesarean delivery versus elective repeat cesarean delivery.

METHODS

We used data from the Discharge Abstract Database that includes all hospital deliveries in Canada (excluding Quebec). In our analysis, we included singleton deliveries to women between 37 and 43 weeks gestation who had a single prior cesarean delivery between April 2003 and March 2015. The primary outcomes were severe maternal morbidity and mortality, and serious neonatal morbidity and mortality. We used logistic regression to estimate adjusted rate ratios (RRs) and 95% confidence intervals (CIs).

RESULTS

Absolute rates of severe maternal morbidity and mortality were low but significantly higher after attempted vaginal birth after cesarean delivery compared with elective repeat cesarean delivery (10.7 v. 5.65 per 1000 deliveries, respectively; adjusted RR 1.96, 95% CI 1.76 to 2.19). Adjusted rate differences in severe maternal morbidity and mortality, and serious neonatal morbidity and mortality were small (5.42 and 7.09 per 1000 deliveries, respectively; number needed to treat 184 and 141, respectively). The association between vaginal birth after cesarean delivery, and serious neonatal morbidity and mortality showed a temporal worsening (adjusted RR 0.94, 95% CI 0.77 to 1.15 in 2003-2005; adjusted RR 2.07, 95% CI 1.83 to 2.35 in 2012-2014).

INTERPRETATION

Although absolute rates of adverse outcomes are low, attempted vaginal birth after cesarean delivery continues to be associated with higher relative rates of severe morbidity and mortality in mothers and infants. Temporal worsening of infant outcomes after attempted vaginal birth after cesarean delivery highlights the need for greater care in selecting candidates, and more careful monitoring of labour and delivery.

[An analysis of caesarean sections in Uruguay by type of hospital]

OBJECTIVE

To analyse on a comparative basis the incidence of caesarean sections among the different health care systems in Uruguay and with respect to the World Health Organization's (WHO) standards, taking into account the medical-obstetric characteristics of the births, particularly, the Robson classification.

METHODS

We examine 190,847 births registered by the Perinatal Information System in Uruguay between 2009 and 2014 by type of health care system. Using logit models, we analyse the probability of caesarean section taking into account the Robson classification, other risk factors and the mothers' characteristics. We compared the caesarean rates predicted by the different subsystems for a common population. Furthermore, we contrast the caesarean rates observed in each subsystem with the rates that resulted if the Uruguayan hospitals followed the guidelines of the sample of WHO reference hospitals.

RESULTS

Private health systems in Uruguay exhibit a much higher incidence of caesarean sections than public ones, even after considering the medical-obstetric characteristics of the births. Caesarean rates are more than 75% higher than those observed if the WHO standards are applied.

CONCLUSIONS

Uruguay has a very high incidence of caesarean sections with respect to WHO standards, particularly, in the private sector. This fact is unrelated to the clinical characteristics of the births.

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.

Analysis of caesarean sections using Robson 10-group classification system in a university hospital in eastern Ethiopia: a cross-sectional study

OBJECTIVE

To analyse caesarean section (CS) using Robson 10-group classification system in an Ethiopian university hospital.

DESIGN

Cross-sectional study.

SETTING

A university hospital in eastern, Ethiopia.

PARTICIPANTS

980 women who underwent CS from January 2016 to April 2017.

MAIN OUTCOME

Robson groups (1-10-based on gestational age, fetal presentation, number of fetus, onset of labour and history of CS) and indications for CS.

RESULTS

Robson group 3 (multiparous women with single cephalic full-term pregnancy in spontaneous labour with no history of CS), group 5 (multiparous women with single cephalic full-term pregnancy with history of CS) and group 1 (single cephalic nulliparous women full-term pregnancy in spontaneous labour) were the major contributors to the overall CS at 21.4%, 21.1% and 19.3%, respectively. The three major indications for CS were fetal compromise (mainly fetal distress), obstructed labour (mainly cephalopelvic disproportion) and previous CS.

CONCLUSION

Robson groups 3, 5 and 1 were the major contributors to the overall CS rate. Fetal compromise, obstructed labour and previous CS were the underlying indications for performing CS. Further study is required to assess the appropriateness of the indications and to reduce CS among the low-risk groups (groups 1 and 3).

Impact of recommended changes in labor management for prevention of the primary cesarean delivery

BACKGROUND

The dramatic rise in cesarean delivery rates worldwide in recent decades, without evidence of a concomitant decrease in cerebral palsy rates, has raised concerns about its potential negative consequences for maternal and infant health. In 2014, the American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine jointly published an Obstetric Care Consensus for safe prevention of the primary cesarean delivery.

OBJECTIVE

We sought to assess whether modification of our protocol to implement these recommendations helped to decrease our primary cesarean delivery rate safely.

STUDY DESIGN

This is a before-and-after retrospective cohort study at a university referral hospital. In March 2014, the threshold for defining active labor changed from 4 to >6 cm and arrest of first-stage labor from lack of cervical change despite regular contractions after 3 hours of oxytocin administration with amniotomy and epidural anesthesia to no change after 4 hours of adequate or 6 hours of inadequate contractions in women with an epidural. The definition of second-stage arrest of labor changed simultaneously from lack of progress for 3 hours with adequate contractions in women with epidural anesthesia to no progress for ≥4 hours in nulliparas or 3 hours in multiparas with an epidural. We compared maternal and neonatal outcomes over two 1 year periods: from March 2013 to February 2014 (before, preguideline) and from June 2014 to May 2015 (after, postguideline). We included all women with singleton pregnancies at ≥37 weeks' gestation, in vertex presentation, in spontaneous or induced labor, and with epidural anesthesia. We excluded women with an elective or previous cesarean delivery and those with obstetric or fetal complications.

RESULTS

This study included 3283 and 3068 women in the before and after periods, respectively. The groups had similar general and obstetric characteristics. The global cesarean delivery rate decreased significantly from 9.4% in the preguideline to 6.9% in the postguideline period (odds ratio, 0.71; 95% confidence interval, 0.59-0.85; P < .01). The cesarean delivery rate for arrest of first-stage labor fell by half, from 1.8% to 0.9% (odds ratio, 0.51; 95% confidence interval, 0.31-0.81; P < .01) but was significant only among nulliparous women. The cesarean delivery rate for second-stage arrest of labor decreased but not significantly between periods (1.3% vs 1.0%; odds ratio, 0.73; 95% confidence interval, 0.44-1.22; P = .2), and the cesarean delivery rate for failure of induction remained similar (3.7% vs 3.5%; odds ratio, 1.06; 95% confidence interval, 0.06-13.24; P = .88). The median duration of labor before cesarean delivery also became significantly longer among nulliparous women during the later period. Maternal and neonatal outcomes did not differ between the 2 periods, except that the rate of 1 minute Apgar score <7 fell significantly in the later period (8.4% vs 6.9%; odds ratio, 0.80; 95% confidence interval, 0.66-0.97; P = .02).

CONCLUSION

The modification of our protocol by implementing the new consensus recommendations was associated with a reduction of the rate of primary cesarean delivery performed for arrest of labor with no apparent increase in immediate adverse neonatal outcomes in nulliparous women at term with singleton pregnancies in vertex presentation and with epidural anesthesia. Further studies are needed to assess the long-term maternal and neonatal safety of these policies.

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.

No. 281-Classification of Caesarean Sections in Canada: The Modified Robson Criteria

OBJECTIVE

To advocate for the use of a common classification system for Caesarean section across Canada.

OPTIONS

A variety of clinical parameters for classification were considered.

OUTCOMES

Consideration of a common system for classifying Caesarean section.

EVIDENCE

Studies published in English from 1976 to December 2011 were retrieved through searches of Medline and PubMed, using appropriate controlled vocabulary and key words (Caesarean section, vaginal birth after Caesarean, classification) . Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies. Grey (unpublished) literature was identified through searching the web sites of health technology assessment and health technology assessment-related agencies, clinical practice guideline collections, clinical trial registries, and the web sites of national and international medical specialty societies .

VALUES

The studies reviewed were classified according to criteria described by the Canadian Task Force on Preventive Health Care, and the recommendation for practice ranked according to this classification (Table 1).

SPONSORS

The Society of Obstetricians and Gynaecologists of Canada.

RECOMMENDATION

Modified Robson criteria should be used to enable comparison of Caesarean section rates and indications (III-B).