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Habteyes AT, Mekuria MD, Negeri HA, Kassa RT, Deribe LK, Sendo EG. Prevalence and associated factors of caesarean section among mothers who gave birth across Eastern Africa countries: Systematic review and meta-analysis study. Heliyon 2024; 10:e32511. [PMID: 38952380 PMCID: PMC11215273 DOI: 10.1016/j.heliyon.2024.e32511] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Revised: 06/03/2024] [Accepted: 06/05/2024] [Indexed: 07/03/2024] Open
Abstract
Background Caesarean section (CS) rate increased dramatically worldwide, exceeding the World Health Organization's benchmark (10-15 %) in many countries. This rate varies in different regions of the continent. Using various study designs, researchers from across East African countries investigated the prevalence of caesarean section and the factor associated with it but no study shows a pooled prevalence of caesarean section in the Eastern African region. Therefore, this review aimed to systematically summarize and estimate the pooled prevalence of caesarean section and its associated factors in Eastern Africa, 2023. Methods PubMed, Web of Science, EMBASE, Scopus and CINAHL were rigorously searched to find relevant studies. All identified observational studies reporting the prevalence of CS and its associated factors in East Africa published till August 2023 were considered. Heterogeneity across the studies was evaluated using the I2 test. Publication bias was assessed by funnel plot and Egger's regression test. Finally, a random effect meta-analysis model was computed to estimate the pooled prevalence of CS and qualitative analysis was employed for associated factors. The study protocol was registered in PROSPERO. Results This review was assessed using twenty-six eligible studies from a total of 2223 articles with a total of 600,431 participants. In this meta-analysis, the pooled prevalence of caesarean section in Eastern Africa was 24.0 % (95%CI: 22-27 %). The highest pooled prevalence of caesarean section was in Ethiopia, 28.30 % (95%CI; 21.3-35.2 %), and the lowest was seen in Uganda, 11.9 % (95%CI; 7.9-15.9 %). Urban residency, having high level of wealth asset, education level college and above, advanced maternal age, big birth weight, history of previous caesarean section, private institution delivery, multiple pregnancies, pregnancy-induced hypertension, antepartum haemorrhage and fetal malpresentation were linked with a greater likelihood of having CS. Conclusions and recommendation: The overall pooled prevalence of CS in Eastern Africa was high compared to the WHO proposed recommended range. Therefore, the finding implies that each East African countries Ministry of Health and health care professionals shall be given particular emphasis made on strengthening antenatal care services and ensure more women have access to skilled healthcare professionals during childbirth. This can help in providing appropriate interventions, support to women and reducing the need for emergency and unnecessary CSs. The result of this research are a baseline data for future researchers to conduct further studies to better understand the reasons behind the high rates and identify potential interventions and solutions specific to the African context.PROSPERO protocol number: CRD42023440131.
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Affiliation(s)
- Abrham Tesfaye Habteyes
- Department of Midwifery, College of Medicine & Health Sciences, Dilla University, Dilla, Ethiopia
| | - Mihret Debebe Mekuria
- School of Nursing and Midwifery, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Haweni Adugna Negeri
- School of Nursing and Midwifery, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Roza Teshome Kassa
- School of Nursing and Midwifery, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Leul Kitaw Deribe
- School of Nursing and Midwifery, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Endalew Gemechu Sendo
- School of Nursing and Midwifery, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
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Golbasi C, Golbasi H, Bayraktar B, Omeroglu I, Vural T, Sahingoz Yildirim AG, Ekin A. Cesarean delivery rates based on time and indication using the Robson Ten-Group Classification System: Assessment at a Turkish tertiary center. J Obstet Gynaecol Res 2023; 49:883-892. [PMID: 36502809 DOI: 10.1111/jog.15522] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2022] [Accepted: 11/29/2022] [Indexed: 12/14/2022]
Abstract
OBJECTIVE This study aimed to evaluate increasing cesarean delivery (CD) rates, their causes, and changes over the years in a Turkish tertiary center using the Robson Ten-Group Classification System (RTGCS). METHODS Data of deliveries involving birth weight of ≥500 g or ≥24 weeks of gestation period from 2013 to 2020 were retrospectively collected and classified from the hospital digital record system using obstetric concepts and parameters described in the RTGCS. RESULTS The overall CD rate for all births (69051) from 2013 to 2020 was 55.5%. Groups 3, 5, and 1 were the most represented groups (29.1%, 23.9%, and 19.4%, respectively). The major contributors to the overall CD rate were Groups 5, 2, and 10 (23.8%, 9.9%, and 5.6%, respectively). Groups 2 and 4 (nullipara, multipara, single cephalic at term) had high CD rates associated with high rates of pre-labor CD (88.9% and 73.3%, respectively). The CD rate was 99.7% in Group 5, which showed recurrent CD, and 67.2% in Group 10. The overall CD rate was 60.8% in 2020 owing to the significant increase in the contributions by Groups 5, 8, and 10. The most common indication for CD was previous CD (46.1%), fetal distress (13.2%), and cephalopelvic disproportion (CPD) (8%). CONCLUSION Groups 1, 2, 5, and 10 were the major contributors to the overall CD rate at this tertiary center. To reduce overall CD rates, policies that reduce primary CD and support vaginal delivery after cesarean section should be established.
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Affiliation(s)
- Ceren Golbasi
- Department of Obstetrics and Gynecology, Izmir Tinaztepe University Faculty of Medicine, Izmir, Turkey
| | - Hakan Golbasi
- Department of Obstetrics and Gynecology Division of Perinatology, University of Health Sciences Tepecik Training and Research Hospital, Izmir, Turkey
| | - Burak Bayraktar
- Department of Obstetrics and Gynecology, University of Health Sciences Tepecik Training and Research Hospital, Izmir, Turkey
| | - Ibrahim Omeroglu
- Department of Obstetrics and Gynecology Division of Perinatology, University of Health Sciences Tepecik Training and Research Hospital, Izmir, Turkey
| | - Tayfun Vural
- Department of Obstetrics and Gynecology, University of Health Sciences Tepecik Training and Research Hospital, Izmir, Turkey
| | - Alkim Gulsah Sahingoz Yildirim
- Department of Obstetrics and Gynecology Division of Perinatology, University of Health Sciences Tepecik Training and Research Hospital, Izmir, Turkey
| | - Atalay Ekin
- Department of Obstetrics and Gynecology Division of Perinatology, University of Health Sciences Tepecik Training and Research Hospital, Izmir, Turkey
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Shukla M, Mohan M, van Duinen A, Gadgil A, Bakker J, Bhushan P, Roy N. Assessing geographical and economic inequalities in caesarean section rates between the districts of Bihar, India: a secondary analysis of the National Family Health Survey. BMJ Open 2022; 12:e055326. [PMID: 34992116 PMCID: PMC8739431 DOI: 10.1136/bmjopen-2021-055326] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND In Bihar, one of the most populous and poorest states in India, caesarean sections have increased over the last decade. However, an aggregated caesarean section rate at the state level may conceal inequities at the district level. OBJECTIVES The primary aim of this study was to analyse the inequalities in the geographical and socioeconomic distribution of caesarean sections between the districts of Bihar. The secondary aim was to compare the contribution of free-for-service government-funded public facilities and fee-for-service private facilities to the caesarean section rate. SETTING Bihar, with a population in the 2011 census of approximately 104 million people, has a low GDP per capita (US$610), compared with other Indian states. The state has the highest crude birth rate (26.1 per 1000 population) in India, with one baby born every two seconds. Bihar is divided into 38 administrative districts, 101 subdivisions and 534 blocks. Each district has a district (Sadar) hospital, and six districts also have one or more medical college hospitals. METHODS This retrospective secondary data analysis was based on open-source national datasets from the 2015 and 2019 National Family Health Surveys, with respective sample sizes of 45 812 and 42 843 women aged 15-49 years. PARTICIPANTS Secondary data analysis of pregnant women delivering in public and private institutions. RESULTS The caesarean section rate increased from 6.2% in 2015 to 9.7% in 2019 in Bihar. Districts with a lower proportion of poor population had higher caesarean section rates (R2=0.45) among all institutional births, with 10.3% in private and 2.9% in public facilities. Access to private caesarean sections decreased (R2=0.46) for districts with poorer populations. CONCLUSION Marked inequalities exist in access to caesarean sections. The public sector needs to be strengthened to improve access to obstetric services for those who need it most.
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Affiliation(s)
- Minal Shukla
- Dept of Surgery, WHO Collaboration Centre for Research in Surgical Care Delivery in LMICs, Mumbai, Maharashtra, India
| | - Monali Mohan
- Dept of Surgery, WHO Collaboration Centre for Research in Surgical Care Delivery in LMICs, Mumbai, Maharashtra, India
| | - Alex van Duinen
- Faculty of Medicine and Health Sciences Department of Cancer Research and Molecular Medicine, NTNU Fakultet for ingeniorvitenskap og teknologi Trondheim, Trondheim, Norway
- Department of Surgery, St Olav's Hospital Universitetssykehuset i Trondheim, Trondheim, Norway
| | - Anita Gadgil
- Dept of Surgery, WHO Collaboration Centre for Research in Surgical Care Delivery in LMICs, Mumbai, Maharashtra, India
| | - Juul Bakker
- Médecins Sans Frontières, Amsterdam, The Netherlands
| | - Pranav Bhushan
- Aspirational Districts Unit, Ministry of Health and Family Welfare, Govt of India, New Delhi, India
| | - Nobhojit Roy
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
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Geze S, Tura AK, Fage SG, van den Akker T. Can the Robson 10 Group Classification System help identify which groups of women are driving the high caesarean section rate in major private hospitals in eastern Ethiopia? A cross-sectional study. BMJ Open 2021; 11:e047206. [PMID: 34446486 PMCID: PMC8395281 DOI: 10.1136/bmjopen-2020-047206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE The rates of caesarean section (CS) in Ethiopian private hospitals are high compared with those in public facilities, and there are limited descriptions of groups of women contributing to these high rates. The objective of this study was to describe the groups contributing to increased CS rates using the Robson classification in two major private hospitals in eastern Ethiopia. DESIGN Cross-sectional study. SETTING Two major private hospitals in eastern Ethiopia. PARTICIPANTS All women who gave birth from 9 January 2019 to 8 January 2020 in two major private hospitals in eastern Ethiopia. PRIMARY AND SECONDARY OUTCOME MEASURES The primary outcome was the Robson 10 Group Classification System. The secondary outcome was indication for CS as recorded in the medical files. RESULTS Of 1203 births in both hospitals combined during the study period, 415 (34.5%) were by CS. Women with a uterine scar due to previous CS (group 5), single cephalic term multiparous women in spontaneous labour (group 3) and single cephalic term nulliparous women in spontaneous labour (group 1) were the leading groups contributing 33%, 27.5% and 17.1%, respectively. The leading documented indications were fetal compromise (29.4%), previous CS (27.2%) and obstructed labour (12.3%). CONCLUSION More than three-fourths of CS were performed among Robson groups 5, 3 and 1, indicating inadequate trial of labour after CS or management of labour among relatively low-risk groups (3 and 1). Improving management of spontaneous labour and strengthening clinical practice around safely providing the option of vaginal birth after CS practice are strategies required to reduce the high CS rates in these private facilities.
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Affiliation(s)
- Shegaw Geze
- Department of Midwifery, College of Health and Medical Sciences, Wolkite University, Wolkite, Ethiopia
- School of Nursing and Midwifery, College of Health and Medical Sciences, Haramaya University, Harar, Ethiopia
| | - Abera Kenay Tura
- School of Nursing and Midwifery, College of Health and Medical Sciences, Haramaya University, Harar, Ethiopia
- Department of Obstetrics and Gynaecology, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - Sagni Girma Fage
- School of Nursing and Midwifery, College of Health and Medical Sciences, Haramaya University, Harar, Ethiopia
| | - Thomas van den Akker
- Athena Institute, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Department of obstetrics and gynaecology, Leiden University Medical Centre, Leiden, The Netherlands
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Evans MI, Britt DW, Evans SM. Mid forceps did not cause "compromised babies" - "compromise" caused forceps: an approach toward safely lowering the cesarean delivery rate. J Matern Fetal Neonatal Med 2021; 35:5265-5273. [PMID: 33494634 DOI: 10.1080/14767058.2021.1876657] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
OBJECTIVE Over 5 decades, Cesarean Delivery rates (CDR) have risen 6-fold while vaginal operative deliveries [VODs] decreased from >20% to ∼3%. Poor outcomes (HIE and cerebral palsy) haven't improved. Potentiating the virtual abandonment of forceps (F), particularly midforceps (Mid), were allegations about various poor neonatal outcomes. Here, we evaluate VOD and CDR outcomes controlling for prior fetal risk metrics (PR) ascertained an hour before birth. METHODS Our 45-year-old database from a labor research unit of moderate/high risk laboring patients (288 NSVDs, 120 Lows, 30 Mids, and 32 CDs) had multiple fetal scalp samples for base excess (BE), pH, cord blood gases (CB), and umbilical artery bloods. ANOVA established relationships between birth methods and outcomes (Cord blood BE and pH and 1 and 5 min Apgar scores); correlations, and two-step multiple regression assessed PR for delivery method and neonatal outcomes. The main outcome measures were correlations of outcome measures with fetal scalp sample BE and pH up to an hour before delivery and fetal reserve index scores scored concurrently. RESULTS NSVDs had the best immediate neonatal outcomes with significantly higher CB pH and BE as compared to forceps and CDs. However, controlling for PR revealed: (1) PR at 1 h before delivery correlated with delivery mode, i.e. the decrements in outcomes were already present before the delivery was performed; and (2) The presumed deleterious effects of interventional deliveries, per se, were significantly reduced, and (3) Fetal Reserve Index predicted neonatal outcomes better than fetal scalp sample BE, pH, or delivery mode. CONCLUSION The historical belief that MF deliveries caused poorer outcomes than NSVDs seems mostly backwards. Appreciating PR's impact on delivery routes, and when appropriate, properly performing VODs could safely reduce CDR. If our approach lowered CDR by only ∼2%, in the United States about 80,000 CDs might be avoided, saving ∼$750 Million yearly. In the post pandemic world, safely apportioning medical expenses will be even more critical than previously.
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Affiliation(s)
- Mark I Evans
- Comprehensive Genetics, Fetal Medicine Foundation of America, New York, NY, USA.,Department of Obstetrics & Gynecology, Icahn School of Medicine at Mt Sinai, Mt Sinai, NY, USA
| | - David W Britt
- Comprehensive Genetics, Fetal Medicine Foundation of America, New York, NY, USA
| | - Shara M Evans
- Comprehensive Genetics, Fetal Medicine Foundation of America, New York, NY, USA.,Gillings School of Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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Abubeker FA, Gashawbeza B, Gebre TM, Wondafrash M, Teklu AM, Degu D, Bekele D. Analysis of cesarean section rates using Robson ten group classification system in a tertiary teaching hospital, Addis Ababa, Ethiopia: a cross-sectional study. BMC Pregnancy Childbirth 2020; 20:767. [PMID: 33298012 PMCID: PMC7727107 DOI: 10.1186/s12884-020-03474-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Accepted: 12/02/2020] [Indexed: 11/10/2022] Open
Abstract
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.
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Affiliation(s)
- Ferid A Abubeker
- Department of Obstetrics and Gynecology, Saint Paul's Hospital Millennium Medical College, Addis Ababa, Ethiopia.
| | - Biruck Gashawbeza
- Department of Obstetrics and Gynecology, Saint Paul's Hospital Millennium Medical College, Addis Ababa, Ethiopia
| | - Thomas Mekuria Gebre
- Department of Obstetrics and Gynecology, Saint Paul's Hospital Millennium Medical College, Addis Ababa, Ethiopia
| | - Mekitie Wondafrash
- Department of Obstetrics and Gynecology, Saint Paul's Hospital Millennium Medical College, Addis Ababa, Ethiopia
| | | | - Demis Degu
- Department of Obstetrics and Gynecology, Saint Paul's Hospital Millennium Medical College, Addis Ababa, Ethiopia
| | - Delayehu Bekele
- Department of Obstetrics and Gynecology, Saint Paul's Hospital Millennium Medical College, Addis Ababa, Ethiopia
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Tognon F, Borghero A, Putoto G, Maziku D, Torelli GF, Azzimonti G, Betran AP. Analysis of caesarean section and neonatal outcome using the Robson classification in a rural district hospital in Tanzania: an observational retrospective study. BMJ Open 2019; 9:e033348. [PMID: 31822545 PMCID: PMC6924846 DOI: 10.1136/bmjopen-2019-033348] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE Caesarean section (CS) rates have increased worldwide in recent decades. In 2015, the WHO proposed the use of the 10-group Robson classification as a global standard for assessing, monitoring and comparing CS rates both within healthcare facilities over time and between them. The aim of this study was to assess the pattern of CS rates according to the Robson classification and describe maternal and perinatal outcomes by group at the Tosamaganga Hospital in rural Tanzania. DESIGN Observational retrospective study. SETTING St. John of the Cross Tosamaganga Hospital, a referral centre in rural Tanzania. PARTICIPANTS 3012 women who gave birth in Tosamaganga Hospital from 1 January to 30 June 2014 and from 1 March to 30 November 2015. RESULTS The overall CS rate was 35.2%, and about 90% of women admitted for labour were in Robson groups 1 through 5. More than 40% of the CS carried out in the hospital were performed on nulliparous women at term with a single fetus in cephalic presentation (groups 1 and 3), and the most frequent indication for the procedure was previous uterine scar (39.2%). The majority of severe neonatal outcomes were observed in groups 1 (27.7%), 10 (24.5%) and 3 (19.1%). CONCLUSION We recorded a high CS rate in Tosamaganga Hospital, particularly in low-risk patients groups (Robson groups 1 and 3). Our analysis of Robson classification and neonatal outcomes suggests the need to improve labour management at the hospital and to provide timely referrals in order to prevent women from arriving there in critical conditions.
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Affiliation(s)
- Francesca Tognon
- Dipartimento di Salute della Donna e del Bambino, Universita degli Studi di Padova Dipartimento di Medicina, Padova, Italy
- Research Unit, Cuamm Medici con l'Africa, Padova, Veneto, Italy
| | - Angela Borghero
- Tosamaganga Council Designated Hospital, Cuamm Medici con l'Africa, Iringa, United Republic of Tanzania
| | - Giovanni Putoto
- Research Unit, Cuamm Medici con l'Africa, Padova, Veneto, Italy
| | - Donald Maziku
- Maternity Department, Tosamaganga Council Designated Hospital, Iringa, United Republic of Tanzania
| | - Giovanni Fernando Torelli
- Tosamaganga Council Designated Hospital, Cuamm Medici con l'Africa, Iringa, United Republic of Tanzania
| | - Gaetano Azzimonti
- Tosamaganga Council Designated Hospital, Cuamm Medici con l'Africa, Iringa, United Republic of Tanzania
| | - Ana Pilar Betran
- UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Reproductive Health and Research, World Health Organization, Geneva, Switzerland
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Cagan M, Tanacan A, Aydin Hakli D, Beksac MS. 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. J Matern Fetal Neonatal Med 2019; 34:1695-1702. [PMID: 31307260 DOI: 10.1080/14767058.2019.1644619] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
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.
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Affiliation(s)
- Murat Cagan
- Department of Obstetrics and Gynecology, Hacettepe University School of Medicine, Ankara, Turkey
| | - Atakan Tanacan
- Department of Obstetrics and Gynecology, Hacettepe University School of Medicine, Ankara, Turkey
| | | | - Mehmet Sinan Beksac
- Department of Obstetrics and Gynecology, Hacettepe University School of Medicine, Ankara, Turkey
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