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

Caesarean section rates in a tertiary teaching hospital in northern Uganda: a retrospective analysis using the robson ten group classification system

BACKGROUND

The Robson Ten Groups Classification System (RTGCS) is increasingly used to assess, monitor, and compare caesarean section (CS) rates within and between healthcare facilities. We evaluated the major contributing groups to the CS rate at Gulu Regional Referral Hospital (GRRH) in Northern Uganda using the RTGCS.

METHODS

We conducted a retrospective analysis of all deliveries from June 2019 through July 2020 at GRRH, Gulu city, Uganda. We reviewed files of mothers and collected data on sociodemographic and obstetric variables. The outcome variables were Robson Ten Groups (1-10) based on parity, gestational age, foetal presentation, number of foetuses, the onset of labour, parity and lie, and history of CS.

RESULTS

We reviewed medical records of 3,183 deliveries, with a mean age of 24.6 ± 5.7 years. The overall CS rate was 13.4% (n = 427). Most participants were in RTGCS groups 3 (43.3%, n = 185) and 1 (29.2%, n = 88). The most common indication for CS was prolonged labour (41.0%, n = 175), followed by foetal distress (19.9%, n = 85) and contracted pelvis (13.6%, n = 58).

CONCLUSION

Our study showed that GRRH patients had a low-risk obstetric population dominated by mothers in groups 3 and 1, which could explain the low overall CS rate of 13.4%. However, the rates of CS among low-risk populations are alarmingly high, and this is likely to cause an increase in CS rates in the future. We recommend group-specific interventions through CS auditing to lower group-specific CS rates.

Obstetric risk profiles and causes of death: Estimating their association with cesarean sections among maternal deaths in Mexico

BACKGROUND

Maternal mortality is a critical indicator of healthcare quality, and in Mexico, this has become increasingly concerning due to the stagnation in its decline, alongside a concurrent increase in cesarean section (C-section) rates. This study characterizes maternal deaths in Mexico, focusing on estimating the association between obstetric risk profiles, cause of death, and mode of delivery.

METHODS

Utilizing a retrospective observational design, 4,561 maternal deaths in Mexico from 2010-2014 were analyzed. Data were sourced from the Deliberate Search and Reclassification of Maternal Deaths database, alongside other national databases. An algorithm was developed to extract the Robson Ten Group Classification System from clinical summaries text, facilitating a nuanced analysis of C-section rates. Information on the reasons for the performance of a C-section was also obtained. Logistic regression and multinomial logistic regression models were used to estimate the relation between obstetric risk factors, mode of delivery and causes of maternal death, adjusting for covariates.

RESULTS

Among maternal deaths in Mexico from 2010-2014, 47.1% underwent a C-section, with a significant history of previous C-sections observed in 31.4% of these cases, compared to 17.4% for vaginal deliveries (p<0.001). Early prenatal care in the first trimester was more common in C-section cases (46.8%) than in vaginal deliveries (38.3%, p<0.001). A stark contrast was noted in the place of death, with 82.4% of post-C-section deaths occurring in public institutions versus 69.1% following vaginal births. According to Robson's classification, the highest C-section rates were in Group 4 (67.2%, p<0.001) and Group 8 (66.9%, p<0.001). Logistic regression analysis revealed no significant difference in the odds of receiving a C-section in private versus other settings after adjusting for Robson criteria (OR: 1.21; 95% CI: 0.92, 1.60). A prior C-section significantly increased the likelihood of another (OR: 2.38; CI 95%: 2.01, 2.81). The analysis also indicated C-sections were significantly tied to deaths from hypertensive disorders (RRR = 1.25, 95% CI [1.12, 1.40]). In terms of indications, 6.3% of C-sections were performed under inadequate indications, while the indication was not identifiable in 33.1% of all C-sections.

CONCLUSIONS

This study highlights a significant overuse of C-sections among maternal deaths in Mexico (2010-2014), revealed through the Robson classification and ana analysis of the reported indications for the procedure. It underscores the need for revising clinical decision-making to promote evidence-based guidelines and favor vaginal deliveries when possible. High C-section rates, especially noted disparities between private and public sectors, suggest economic and non-clinical factors may be at play. The importance of accurate data systems and further research with control groups to understand C-section practices' impact on maternal health is emphasized.

Study of Caesarean Section Births in a Tertiary Care Hospital in Mumbai Using Robson Classification System

Introduction

Robson ten-group classification system is recommended by WHO (World health organization) as a global standard for assessment and monitoring caesarean section (CS) rates. This classification is simple and robust. It is prospective, easily reproducible and clinically relevant.

Methodology

We conducted a prospective observational study of CS births at a tertiary care institute. Caesarean births in a tertiary care hospital were classified using Robson classification system as recommended by WHO. The study was conducted for period of 6 months duration. The ethics committee of the institute approved this study. We enrolled 4771 consecutive women who delivered during this study period. We included patients who had vaginal delivery as well as those who had delivery by CS. Both live births and stillbirths (of at least 500-g birth weight or at least 22 weeks gestation (according to WHO recommendations) were included in this study.

Results

During this study period, we had 4771 deliveries, out of which 2231 pregnant women (46.76%) were delivered by CS as compared to 2540 vaginal deliveries. Women with previous CS (term with single cephalic pregnancy) were included in Robson group 5. Group 5 had the highest CS rate (13.41%). Robson group 5, 1 and 10 were the largest contributors to the high CS rates at our institute.

Conclusion

In our study, 4771 deliveries were conducted during this study period (6 months). Out of 4771 deliveries, CS was done in 2231 pregnant women (46.76%). 2540 women had vaginal deliveries. Group 5 (13.41%) which comprised of women with previous CS had the highest CS rate followed by group 1 and group 10. The second largest contribution was from Group 1 with CS rate of 9.01%. Robson Group 1 included nulliparous term women with single cephalic pregnancy in spontaneous labour. Group 10 was the third largest contributor to the overall CS. Group 10 included women who delivered preterm (single cephalic presentation). Group 10 contributed to 8.09% of overall CS rate. We should make every effort to provide CS for women requiring this procedure, rather than work towards achieving a specific rate for CS.

Factors Associated with High Rates of Caesarean Deliveries: A Cross Sectional Study Classifying Deliveries According to Robson in Mengo Hospital Kampala

Introduction

The number of caesarean section (CS) continues to rise worldwide. CS can improve outcomes in infants and mothers. However, if used improperly, the potential harm can outweigh the potential benefits.

Aim

The study was to determine the factors associated with high cesarean section rates at Mengo Hospital.

Methods

This cross-sectional study used a mixed-method approach that included a retrospective review of 1276 casebooks using the Robson Ten Group Classification System (RTGCS) for births that occurred at Mengo Hospital in December 2018, January, and February 2019. Questionnaire was used for data collection from 200 mothers on second day after birth from 24th May to 19th July 2019. Eight key informants were interviewed within the same period. Quantitative data were analyzed using STATA V.14, thematic analysis for qualitative data. Univariate, bivariate, and multivariate analyses were performed to determine the association between predisposing factors and outcome variables using chi-square and modified Poisson.

Results

Caesarean section rate (CSR) from casebooks was 49% and 64% from the primary data. Group 5(Previous CS, single cephalic, >37 weeks) had (35.4%) to the total number of cesarean deliveries, followed by Group 1 (Nulliparous, single cesarean deliveries, >37 weeks in spontaneous labour), with 18.4%. Group 3 (ultiparous (excluding previous CS), single cephalic, >37 weeks of spontaneous labor) with (13.7%). The common indications from casebooks were a previous scar (32%), obstructed labor (18%), and previous scar (97.6%). Presence of an obstetric indication, influence of husband, friends, relatives, and mother's desire for a CS were closely associated with caesarean delivery. Mothers said that occurrence of CS was due to health workers reducing the stress of monitoring labour and financial benefits from CS deliveries by the hospital.

Conclusion

Repeat CS made the highest CSR contribution; therefore, strategies to reduce the frequency of the procedure should include avoiding medically unnecessary primary CS and encouraging vaginal birth after previous CS where applicable.

Observation of a quality improvement initiative to contextually adapt and use Robson classification in real time to collect data around CS delivery and to develop strategies to reduce CS rate

The rising trend in caesarean section (CS) rate is a global concern and, in this hospital too, it rose from 21.5% in 2010 to 32.6% in 2018. The team followed the point of care quality improvement methodology and conducted a series of Plan-Do-Study-Act cycles to contextually modify and adapt Robson classification into the existing workflow to improve the process of documentation and data collection for CS in the first 6 months (January 2019-June 2019) and then to use these data to develop strategies to reduce CS rate below 30% in the next 18 months.To evaluate the impact of developed strategies, the team plotted the data on Statistical Process Control (XmR) chart. The baseline mean CS rate was 32.6%. The team observed a shift in the CS rate data twice, between April 2020 and December 2020 and between August 2021 and February 2021 with the mean 27.8% and 28.9%, respectively. October 2021 onwards, the team also observed a sustained reduction in the CS rate in women undergoing CS who had one previous CS. The mean CS rate reduced from 94% to 86%.The reductions in the CS rate were not sustained and followed by an increase again. The project highlighted the complexity of the factors related to CS delivery and the multidimensional barriers of sustaining the reduction in the CS rate. This is a well-sustained ongoing QI intervention and the team is further working on identifying the underlying factors to improve the efficacy of the interventions to sustain the reduction in the CS rate.This hospital represents the general population of North India seeking care in public healthcare facilities. Therefore, despite being a single-centre study, the population served and interpretations drawn from this study are generalisable to other hospitals with similar settings.

Robson classification of caesarean births: implications for reducing caesarean section rate in a private tertiary hospital in Nigeria

BACKGROUND

Caesarean section (CS) is a potentially lifesaving obstetric procedure. However, there are concerns about the rising CS rate in many countries of the world including Nigeria. The Ten-Group Robson classification system is presently recommended as an effective monitoring tool for comparing CS rates and identifying target groups for intervention aimed at reducing the rates. The aim of this study was to evaluate the cesarean section rate and the groups with the highest risk of CS at the obstetric unit of Babcock University Teaching Hospital (BUTH), using the Robson classification system.

METHODS

A cross-sectional study involving 447 women who gave birth at the obstetric unit of BUTH between August 2020 and February 2022. Relevant information was retrieved from the delivery records of the study participants. Data were analyzed using the IBM-SPSS Statistics for Windows version 23.0 (IBM Corp., Armonk, NY, USA).

RESULTS

The overall CS rate was 51.2%. Multiparous women with previous CS, single, cephalic, term (group 5); nulliparous women, single cephalic, term, with induced labour or pre-labour CS (group 2); women with preterm single cephalic, term (group 10); and single cephalic term multiparous women in spontaneous labour (group 3) were the largest contributors to CS rate accounting for 34.5%, 14.0%, 12.6%, and 10.0% respectively. The commonest indication for CS was previous CS (87; 38.0%), followed by poor progress in labour (24; 10.5%).

CONCLUSIONS

The CS rate in BUTH is high and Robson groups 5, 2 10 and 3 were the major contributors to this high rate. Interventions directed at reducing the first CS by improving management of spontaneous and induced labours; and strengthening clinical practice around encouraging vaginal birth after CS will have the most significant effect on reducing CS rate.

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.

Obstructed labor and its effect on adverse maternal and fetal outcomes in Ethiopia: A systematic review and meta-analysis

Background

Obstructed labor is one of the five major causes of maternal mortality and morbidity in developing countries. In Ethiopia, it accounts for 19.1% of maternal death. The current review aimed to assess maternal and perinatal outcomes of obstructed labor in Ethiopia.

Methods

Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline was followed for this systematic review and meta-analysis. A literature search was made using PubMed/MEDLINE, CINAHL, Summon country-specific search, and Cochrane Libraries’ online databases. Search terms were adverse outcome, obstructed labor, maternal outcome, fetal outcome, and Ethiopia. The Newcastle-Ottawa scale (NOS), based on a star scoring system, was used to assess the quality of the included studies. The meta-analysis was conducted using STATA 16 software. The pooled prevalence of an adverse maternal outcome, fetal outcome, and association between adverse outcome and obstructed labor was calculated using a random-effects model. Egger’s test and funnel plot were used to evaluate publication bias.

Result

Eighty-seven studies were included in this review, with an overall sample size of 104259 women and 4952 newborns. The pooled incidence of maternal death was estimated to be 14.4% [14.14 (6.91–21.37). The pooled prevalence of uterine rupture and maternal near-miss was 41.18% (95% CI: 19.83, 62.54) and 30.5% [30.5 (11.40, 49.59) respectively. Other complications such as postpartum hemorrhage, sepsis, obstetric fistula, hysterectomy, bladder injury, cesarean section, and labor abnormalities were also reported. The pooled prevalence of perinatal death was 26.4% (26.4 (95% CI 15.18, 37.7). In addition, the association of obstructed labor with stillbirth, perinatal asphyxia, and meconium-stained amniotic fluid was also demonstrated.

Conclusions

In Ethiopia, the incidence of perinatal and maternal mortality among pregnant women with obstructed labor was high. The rate of maternal death and maternal near miss reported in this review was higher than incidences reported from high-income and most low and middle-income countries. Uterine rupture, postpartum hemorrhage, sepsis, fistula, hysterectomy, and bladder injury were also commonly reported. To improve the health outcomes of obstructed labor, it is recommended to address the three delay models: enhancing communities’ health-seeking behavior, enhancing transportation for an obstetric emergency with different stakeholders, and strengthening the capacity of health facilities to handle obstetric emergencies.

Cesarean Audit Using Robson Classification at a Tertiary Care Center in Bihar: A Retrospective Study

Background

Since 1985, the international healthcare community has considered the ideal rate for cesarean section (CS) to be between 10% and 15%.However, CS has been increasing both in developed and developing countries. The aim of the present study was to audit CS using Robson’s Ten Group Classification System (TGCS).

Methodology

This retrospective, hospital record-based study was conducted over a period of three years from April 1, 2016, to March 31, 2019, in the Department of Obstetrics and Gynecology at Indira Gandhi Institute of Medical Sciences, Patna, Bihar, India. Data of patients who delivered by CS during this period were recorded and categorized in the 10 groups of TGCS. The size of each group, CS rate, and contribution of each group toward overall CS were calculated. Indications of CS in each group were analyzed, and strategies were planned to optimize the use of CS. The Chi-square test was used to analyse the statistical significance of the differences in the number of CS between the different Robson's groups.

Results

The total number of deliveries was 2,128 during the study period, of which CS was performed in 812 deliveries, with a CS rate of 38.16% in our institute. Robson’s group 5 (34.97%) was the major contributor to the overall CS rate, followed by group 2 (26.35%), group 1 (15.51%), and group 10 (7.14%). The incidence of primary CS (61.82%) was more than repeat CS (38.17%). Previous CS, fetal distress, failed induction, arrest of labor, and malpresentation were the main indications for CS.

Conclusions

Robson’s TGCS serves as an important tool for auditing CS. Indications of CS among major contributors and primary group should be analyzed regularly and uniform and standard protocols should be used. Standardization of indications for CS, regular audits, and definite protocols will help in reducing the CS rate in our hospital.

Distribution of cesarean delivery by Robson classification and predictors of postspinal anesthesia hypotension in Windhoek referral hospitals: A cross-sectional study

Background

There are concerns that high cesarean section (CS) rates are driven by nonmedical indications and unmitigated maternal hypotension following spinal anesthesia (SA) has materno fetal effects.

Aims

Our objective was to investigate CS rates using Robson classification, identify patient groups for focused intervention as well as assess the incidence and predictors of maternal hypotension following SA for cesarean delivery.

Subjects and Methods

A cross sectional design was employed over 3 months (February-April, 2019). Data about total deliveries (vaginal and operative) were obtained from the hospital medical records. For parturients who had CS, variables which covered maternal characteristics, conduct of anesthesia, and the index pregnancy according to Robson classification system were entered into a proforma designed for the study.

Results

The total deliveries were 3031, of which 556 were CSs, giving a CS rate of 18.3%. Twenty one nonconsenting parturients were excluded, so 535 responded. Robson groups 5, 10, and 1 combined contributed 75% [401/535] to the overall CS. Two or more previous CS, 29.7% [159/535], was the main indication for performing CS, followed by maternal request 12.9% [69/535]. The incidence of maternal hypotension was 62.6% (293/468); the independent predictors were elective CS and having comorbidities.

Conclusion

We found a low CS rate and Robson groups 5, 10, and 1 were the major contributors - previous CS (≥2) and maternal request were the predominant indications for performing CS. The independent predictors of SA induced hypotension were presence of comorbidities and elective CS.

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.

Magnitude and associated factors of caesarean section deliveries among women who gave birth in Southwest Ethiopia: institutional-based cross-sectional study

BACKGROUND

Caesarean section is a life-saving comprehensive obstetric procedure of women and newborn performed during childbirth-related complications and should be universally accessible for all pregnant mothers globally. Appropriate use of caesarean section can reduce maternal and perinatal mortality. However, inappropriate use of caesarean section can negatively affect infant health, women health, and future pregnancies. The magnitude and factors associated with caesarean section delivery were not consistent and will vary between different hospitals of Ethiopia. Hence, this study aimed at assessing the magnitude and factors associated with caesarean section deliveries in Southwest Ethiopia.

METHODS AND MATERIALS

An institutional-based cross-sectional study was conducted from January 1 to February 29, 2020. A systematic random sampling technique was used to select 551 study participants. A pretested, structured, and face-to-face interview was used to collect data. Data were entered into Epi-data version 4.2.0 and exported to SPSS version 23 for analysis. Bivariate and multivariate analyses were used to identify factors associated with caesarean section deliveries. P values < 0.05 result were considered as a statistically significant association.

RESULTS

The magnitude of caesarean section deliveries was found to be 32.5 % (95 % CI; 28.6%-36.7 %). Mothers resided in an urban area [AOR = 2.58, (95% CI; 1.66-4.01)], multiple pregnancies [AOR = 3.15, (95% CI; 1.89-5.23), malpresentation [AOR = 3.05, (95% CI; 1.77-5.24)], and previous history of caesarean section [AOR = 3.55, (95% CI; 2.23-5.64) were factors associated with caesarean section deliveries.

CONCLUSIONS

Caesarean section deliveries were found high in the study area. Mothers resided in an urban area, multiple pregnancies, malpresentation, and previous history of caesarean section were factors associated with caesarean section deliveries. Therefore, counselling of mothers on the risk of giving birth through elective caesarean section without absolute and relative medical indications and giving enough time for the trial of vaginal birth after caesarean section are recommended.

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

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.

Pregnancy outcomes at Mizan-Tepi University Teaching Hospital: A Comparison to the Ethiopian Demographic and Health Surveys

Background:

To compare outcomes at Mizan-Tepi University Teaching Hospital to national and regional data and to plan quality improvement and research studies based on the results.

Methods:

This study was a prospective hospital-based cross-sectional analysis of a convenience sample of 1, 000 women who delivered at Mizan-Tepi University Teaching Hospital.

Results:

Our convenience sample was young (median age 24 years) with a primarily school level or less of education (68.6%). Only about 5% of women had a history of prior cesarean birth, 2.1% reported they were human immunodeficiency virus seropositive, and the median number of prenatal visits was four. Women were commonly admitted in spontaneous labor (84.5%), transferred from another facility (49.2%; 96.8% of which were referred from a health center), and had their fetal heart rate auscultated on admission (94.7%). Only 5.2% of women did not deliver within twenty-four hours and the cesarean birth prevalence was 23.4%. Many women were delivered by midwives (73.2%; all unassisted vaginal births), 89.2% were term deliveries, and 92.5% of neonatal birthweights were 2500 grams or heavier. Less than five percent of women delivered stillbirths (4.3%) and 5.7% of livebirths experienced neonatal death by the day of discharge. There were no maternal deaths in the cohort.

Conclusion:

The prevalence of stillbirth and neonatal death were the most notable findings, while there was no maternal death in the cohort.

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

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

OBJECTIVE

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

DESIGN

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

SETTING

Hawassa University Referral Hospital in south Ethiopia.

PARTICIPANTS

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

RESULTS

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

CONCLUSION

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

Use of Cesarean Birth at Mizan Tepi University Teaching Hospital, Mizan Aman, Ethiopia

OBJECTIVES

The objective of this analysis was to review indication and utilization of cesarean birth among Robson Classification of Cesarean Birth subgroups.

METHODS

This study was a prospective hospital-based cross-sectional analysis of a convenience sample of 1,000 women who delivered Mizan Tepi University Teaching Hospital in the summer and fall of 2019.

RESULTS

Data on mode of delivery was available for 993 women, 23.4% of which underwent cesarean birth. The leading indication for cesarean birth was a fetal indication (46.2%), followed by a maternal indication (35.9%); elective cesarean birth was the indication for one cesarean birth. Robson Groups 1 and 3 (primary cesarean among nulliparous and multiparous women) accounted for the largest proportion of the overall population of women (30.2% and 36.8%), and cesarean birth rates within these groups were 19.4% and 16.1%, respectively. In all remaining groups, cesarean birth rates were at least 17.1%, ranging to as high as 100.0%. Pre-labor cesarean was highest in Robson Group 5 (multiparous women with a history of cesarean birth).

CONCLUSION

Further analysis of risk factors associated with cesarean birth in women whose labor was induced or augmented, or those undergoing preterm birth, might offer additional target risk factors to modify.

Global incidence of caesarean deliveries on maternal request: a systematic review and meta-regression

BACKGROUND

Caesarean delivery on maternal request (CDMR) is considered a significant contributor to the unprecedented increase in caesarean deliveries (CDs) for nonclinical reasons. Current literature lacks a reliable assessment of the rate of CDMR, which hinders the planning and delivery of appropriate interventions for reducing CDMR rates.

OBJECTIVES

To conduct a systematic review of the literature and meta-regression to explore the global incidence of CDMR.

SEARCH STRATEGY

PubMed, Embase, CINAHL, Medline, Google scholar and grey literature were searched from January 1985 to May 2019.

SELECTION CRITERIA

Observational studies that report CDMR data were included. We excluded non-English articles, case notes, editorial reviews and articles reporting elective CDs from pregnancy risk factors.

DATA COLLECTION AND ANALYSIS

Two reviewers independently conducted the screening and quality appraisal using a validated tool. The weighted average of CDMR over total deliveries (absolute proportion) and by total CDs (relative proportion) were generated. Quality-effects meta-regression was used to explain the variability of the CDMR estimates by moderators, including study methodology and demography of study participants.

MAIN RESULTS

We identified 31 articles from 14 countries that include 5 million total births. The absolute proportion of CDMR varies between 0.2 and 42.0%, with significant variations across studies and subgroups. The economic status of the country and study year together explained 84% of the absolute and 76% of the relative proportion of CDMR variation.

CONCLUSIONS

An appropriate reporting of CDMR should be a key priority in maternal health policies and practices.

TWEETABLE ABSTRACT

Globally, the proportion of maternal requested caesarean delivery has mostly been influenced by the economic status of the country.

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.

A Systematic Evaluation of Hospital Performance of Childbirth Delivery Modes and Associated Factors in the Friuli Venezia Giulia Region (North-Eastern Italy), 2005-2015

Cesarean sections (CS) have become increasingly common in both developed and developing countries, raising legitimate concerns regarding their appropriateness. Since improvement of obstetric care at the hospital level needs quantitative evidence, using routinely collected health data we contrasted the performance of the 11 maternity centres (coded with an alphabetic letter A to L) of an Italian region, Friuli Venezia Giulia (FVG), during 2005-15, after removing the effect of several factors associated with different delivery modes (DM): spontaneous vaginal delivery (SVD), instrumental vaginal delivery (IVD), overall CS (OCS) and urgent/emergency CS (UCS). A multivariable logistic regression model was fitted for each individual DM, using a dichotomous outcome (1 = each DM; 0 = rest of hospital births) and comparing the stratum specific estimates of every term with their respective reference categories. Results were expressed as odds ratios (OR) with 95% confidence intervals (95%CI). The Benjamini-Hochberg (BH) false discovery rates (FDR) approach was applied to control alpha error due to the large number of statistical tests performed. In the entire FVG region during 2005-2015, SVD were 75,497 (69.1% out of all births), IVD were 7,281 (6.7%), OCS were 26,467 (24.2%) and UCS were 14,106 (12.9% of all births and 53.3% out of all CS). SVD were more likely (in descending order of statistical significance) with: higher number of previous livebirths; clerk/employed occupational status of the mother; gestational age <29 weeks; placentas weighing <500 g; stillbirth; premature rupture of membranes (PROM). IVD were predominantly more likely (in descending order of statistical significance) with: obstructed labour, non-reassuring fetal status, history of CS, labour analgesia, maternal age ≥35 and gestation >40 weeks. The principal factors associated with OCS were (in descending order of statistical significance): CS history, breech presentation, non-reassuring fetal status, obstructed labour, multiple birth, placental weight ≥ 600 g, eclampsia/pre-eclampsia, maternal age ≥ 35 and oligohydramnios. The most important risk factors for UCS were (in descending order of statistical significance): placenta previa/abruptio placenta/ antepartum hemorrage; non-reassuring fetal status, obstructed labour; breech presentation; PROM, eclampsia/pre-eclampsia; gestation 33-36 weeks; gestation 41+ weeks; oligohydramnios; birthweight <2,500 g, maternal age ≥ 35 and cord prolapse. After removing the effects of all other factors, we found great variability of DM rates across hospitals. Adjusting for all risk factors, all hospitals had a OCS risk higher than the referent (hospital G). Out of these 10 hospitals with increased adjusted risk of OCS, 9 (A, B, C, D, E, F, I, J, K) performed less SVD and 5 (A, C, D, I, J) less IVD. In the above 5 centres CS was therefore probably overused. The present study shows that routinely collected administrative data provide useful information for health planning and monitoring. Although the overall CS rate in FVG during 2005-15 was 24.2%, well below the corresponding average Italian national figure (38.1%), the variability of DM rates across FVG maternity centres could be targeted by policy interventions aimed at reducing the recourse to unnecessary CS. In some clinical conditions such as obstructed labor, non-reassuring fetal status, breech presentation, history of CS, higher maternal age and multiple birth, consideration may be given to more conservative DM. The overuse of CS in nulliparas and repeat CS (RCS) should be carefully monitored and subject to audit.

Analysis of caesarean section and neonatal outcome using the Robson classification in a rural district hospital in Tanzania: an observational retrospective study

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.

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

AIM

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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.