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Pasko DN, McGee P, Grobman WA, Bailit JL, Reddy UM, Wapner RJ, Varner MW, Thorp JM, Caritis SN, Prasad M, Saade GR, Sorokin Y, Rouse DJ, Tolosa JE. Comparison of Cesarean Deliveries in a Multicenter U.S. Cohort Using the 10-Group Classification System. Am J Perinatol 2024; 41:1223-1231. [PMID: 35668654 PMCID: PMC9718892 DOI: 10.1055/s-0042-1748527] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
OBJECTIVE We sought to (1) use the Robson 10-Group Classification System (TGCS), which classifies deliveries into 10 mutually exclusive groups, to characterize the groups that are primary contributors to cesarean delivery frequencies, (2) describe inter-hospital variations in cesarean delivery frequencies, and (3) evaluate the contribution of patient characteristics by TGCS group to hospital variation in cesarean delivery frequencies. STUDY DESIGN This was a secondary analysis of an observational cohort of 115,502 deliveries from 25 hospitals between 2008 and 2011. The TGCS was applied to the cohort and each hospital. We identified and compared the TGCS groups with the greatest relative contributions to cohort and hospital cesarean delivery frequencies. We assessed variation in hospital cesarean deliveries attributable to patient characteristics within TGCS groups using hierarchical logistic regression. RESULTS A total of 115,211 patients were classifiable in the TGCS (99.7%). The cohort cesarean delivery frequency was 31.4% (hospital range: 19.1-39.3%). Term singletons in vertex presentation with a prior cesarean delivery (group 5) were the greatest relative contributor to cohort (34.8%) and hospital cesarean delivery frequencies (median: 33.6%; range: 23.8-45.5%). Nulliparous term singletons in vertex (NTSV) presentation (groups 1 [spontaneous labor] and 2 [induced or absent labor]: 28.9%), term singletons in vertex presentation with a prior cesarean delivery (group 5: 34.8%), and preterm singletons in vertex presentation (group 10: 9.8%) contributed to 73.2% of the relative cesarean delivery frequency for the cohort and were correlated with hospital cesarean delivery frequencies (Spearman's rho = 0.96). Differences in patient characteristics accounted for 34.1% of hospital-level cesarean delivery variation in group 2. CONCLUSION The TGCS highlights the contribution of NTSV presentation to cesarean delivery frequencies and the impact of patient characteristics on hospital-level variation in cesarean deliveries among nulliparous patients with induced or absent labor. KEY POINTS · We report on the cesarean delivery frequencies in a multicenter U.S. COHORT . · NTSV gestations (groups 1 and 2) are a primary driver of cesarean deliveries.. · Patient characteristics contributed most to hospital variation in cesarean deliveries in group 2..
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Affiliation(s)
- Daniel N Pasko
- Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Paula McGee
- The George Washington University Biostatistics Center, Washington, District of Columbia
| | - William A Grobman
- Department of Obstetrics and Gynecology, Northwestern University, Chicago, Illinois
| | - Jennifer L Bailit
- Department of Obstetrics and Gynecology, MetroHealth Medical Center-Case Western Reserve University, Cleveland, Ohio
| | - Uma M Reddy
- The Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland
| | - Ronald J Wapner
- Department of Obstetrics and Gynecology, Columbia University, New York, New York
| | - Michael W Varner
- Department of Obstetrics and Gynecology, University of Utah Health Sciences Center, Salt Lake City, Utah
| | - John M Thorp
- Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Steve N Caritis
- Department of Obstetrics and Gynecology, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Mona Prasad
- Department of Obstetrics and Gynecology, The Ohio State University, Columbus, Ohio
| | - George R Saade
- Department of Obstetrics and Gynecology, University of Texas Medical Branch, Galveston, Texas
| | - Yoram Sorokin
- Department of Obstetrics and Gynecology, Wayne State University, Detroit, Michigan
| | - Dwight J Rouse
- Department of Obstetrics and Gynecology, Brown University, Providence, Rhode Island
| | - Jorge E Tolosa
- Department of Obstetrics and Gynecology, Oregon Health and Science University, Portland, Oregon
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Gantt DM, Misselwitz B, Boos V, Reitter A. Errors in the classification of pregnant women according to Robson ten-group classification system. Eur J Obstet Gynecol Reprod Biol 2024; 295:53-57. [PMID: 38335585 DOI: 10.1016/j.ejogrb.2024.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Revised: 01/25/2024] [Accepted: 02/04/2024] [Indexed: 02/12/2024]
Abstract
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.
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Affiliation(s)
| | - Björn Misselwitz
- Federal State Consortium of Quality Assurance Hesse (Landesarbeitsgemeinschaft Qualitätssicherung Hessen, LAGQH), Frankfurter Str. 10, 65760 Eschborn, Germany.
| | - Vinzenz Boos
- Newborn Research, Department of Neonatology, University Hospital Zurich, University of Zurich, Frauenklinikstrasse 10, 8091 Zurich, Switzerland.
| | - Anke Reitter
- Goethe-University Frankfurt, Theodor-Stern-Kai, 60596 Frankfurt am Main, Germany; Department of Obstetrics, Hospital Zollikerberg, Trichtenhauserstrasse 20, 8125 Zollikerberg, Switzerland.
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Palladino R, Balsamo F, Mercogliano M, Sorrentino M, Monzani M, Egidio R, Piscitelli A, Borrelli A, Bifulco G, Triassi M. Impact of SARS-CoV-2 Positivity on Delivery Outcomes for Pregnant Women between 2020 and 2021: A Single-Center Population-Based Analysis. J Clin Med 2023; 12:7709. [PMID: 38137777 PMCID: PMC10744135 DOI: 10.3390/jcm12247709] [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: 11/07/2023] [Revised: 12/08/2023] [Accepted: 12/12/2023] [Indexed: 12/24/2023] Open
Abstract
Despite the existing body of evidence, there is still limited knowledge about the impact of SARS-CoV-2 positivity on delivery outcomes. We aimed to assess the impact of SARS-CoV-2 infection in women who gave birth at the University Hospital "Federico II" of Naples, Italy, between 2020 and 2021. We conducted a retrospective single-center population-based observational study to assess the differences in the caesarean section and preterm labor rates and the length of stay between women who tested positive for SARS-CoV-2 and those who tested negative at the time of labor. We further stratified the analyses considering the time period, dividing them into three-month intervals, and changes in SARS-CoV-2 as the most prevalent variant. The study included 5236 women with 353 positive cases. After vaccination availability, only 4% had undergone a complete vaccination cycle. The Obstetric Comorbidity Index was higher than 0 in 41% of the sample. When compared with negative women, positive ones had 80% increased odds of caesarean section, and it was confirmed by adjusting for the SARS-CoV-2 variant. No significant differences were found in preterm birth risks. The length of stay was 11% higher in positive cases but was not significant after adjusting for the SARS-CoV-2 variant. When considering only positive women in the seventh study period (July-September 2021), they had a 61% decrease in the odds of receiving a caesarean section compared to the fourth (October-December 2020). Guidelines should be implemented to improve the safety and efficiency of the delivery process, considering the transition of SARS-CoV-2 from pandemic to endemic. Furthermore, these guidelines should aim to improve the management of airborne infections in pregnant women.
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Affiliation(s)
- Raffaele Palladino
- Department of Public Health, University “Federico II” of Naples, 80131 Naples, Italy (M.M.); (M.S.); (M.M.); (G.B.)
- Department of Primary Care and Public Health, Imperial College School of Public Health, London SW7 2BX, UK
- Interdepartmental Research Center in Healthcare Management and Innovation in Healthcare (CIRMIS), University “Federico II” of Naples, 80131 Naples, Italy
| | - Federica Balsamo
- Department of Public Health, University “Federico II” of Naples, 80131 Naples, Italy (M.M.); (M.S.); (M.M.); (G.B.)
| | - Michelangelo Mercogliano
- Department of Public Health, University “Federico II” of Naples, 80131 Naples, Italy (M.M.); (M.S.); (M.M.); (G.B.)
| | - Michele Sorrentino
- Department of Public Health, University “Federico II” of Naples, 80131 Naples, Italy (M.M.); (M.S.); (M.M.); (G.B.)
| | - Marco Monzani
- Department of Public Health, University “Federico II” of Naples, 80131 Naples, Italy (M.M.); (M.S.); (M.M.); (G.B.)
| | - Rosanna Egidio
- Clinical Directorate, Academic Hospital “Federico II” of Naples, 80131 Naples, Italy
| | - Antonella Piscitelli
- Azienda Ospedaliera di Rilievo Nazionale (AORN) Dei Colli, Vincenzo Monaldi Hospital, 80122 Naples, Italy
| | - Anna Borrelli
- Clinical Directorate, Academic Hospital “Federico II” of Naples, 80131 Naples, Italy
| | - Giuseppe Bifulco
- Department of Public Health, University “Federico II” of Naples, 80131 Naples, Italy (M.M.); (M.S.); (M.M.); (G.B.)
| | - Maria Triassi
- Department of Public Health, University “Federico II” of Naples, 80131 Naples, Italy (M.M.); (M.S.); (M.M.); (G.B.)
- Interdepartmental Research Center in Healthcare Management and Innovation in Healthcare (CIRMIS), University “Federico II” of Naples, 80131 Naples, Italy
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Muraca GM, Joseph K, Razaz N, Ladfors LV, Lisonkova S, Stephansson O. Crude and adjusted comparisons of cesarean delivery rates using the Robson classification: A population-based cohort study in Canada and Sweden, 2004 to 2016. PLoS Med 2022; 19:e1004077. [PMID: 35913981 PMCID: PMC9377587 DOI: 10.1371/journal.pmed.1004077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Revised: 08/15/2022] [Accepted: 07/15/2022] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND The Robson classification has become a global standard for comparing and monitoring cesarean delivery (CD) rates across populations and over time; however, this classification does not account for differences in important maternal, fetal, and obstetric practice factors known to impact CD rates. The objectives of our study were to identify subgroups of women contributing to differences in the CD rate in Sweden and British Columbia (BC), Canada using the Robson classification and to estimate the contribution of maternal, fetal/infant, and obstetric practice factors to differences in CD rates between countries and over time. METHODS AND FINDINGS We conducted a population-based cohort study of deliveries in Sweden (January 1, 2004 to December 31, 2016; n = 1,392,779) and BC (March 1, 2004 to April 31, 2017; n = 559,205). Deliveries were stratified into Robson categories and the CD rate, relative size of each group and its contribution to the overall CD rate were compared between the Swedish and the Canadian cohorts. Poisson and log-binomial regression were used to assess the contribution of maternal, fetal, and obstetric practice factors to spatiotemporal differences in Robson group-specific CD rates between Sweden and BC. Nulliparous women comprised 44.8% of the study population, while women of advanced maternal age (≥35 years) and women with overweight/obesity (≥25 kg/m2) constituted 23.5% and 32.4% of the study population, respectively. The CD rate in Sweden was stable at approximately 17.0% from 2004 to 2016 (p for trend = 0.10), while the CD rate increased in BC from 29.4% to 33.9% (p for trend < 0.001). Differences in CD rates between Sweden and BC varied by Robson group, for example, in Group 1 (nullipara with a term, single, cephalic fetus with spontaneous labor), the CD rate was 8.1% in Sweden and 20.4% in BC (rate ratio [RR] for BC versus Sweden = 2.52, 95% confidence interval [CI] 2.49 to 2.56, p < 0.001) and in Group 2 (nullipara, single, cephalic fetus, term gestation with induction of labor or prelabor CD), the rate of CD was 37.3% in Sweden and 45.9% in BC (RR = 1.23, 95% CI 1.22 to 1.25, p < 0.001). The effect of adjustment for maternal characteristics (e.g., age, body mass index), maternal comorbidity (e.g., preeclampsia), fetal characteristics (e.g., head position), and obstetric practice factors (e.g., epidural) ranged from no effect (e.g., among breech deliveries; Groups 6 and 7) to explaining up to 5.2% of the absolute difference in the CD rate (Group 2: adjusted CD rate in BC 40.7%, adjusted RR = 1.09, 95% CI 1.08 to 1.12, p < 0.001). Adjustment also explained a substantial fraction of the temporal change in CD rates among some Robson groups in BC. Limitations of the study include a lack of information on intrapartum details, such as labor duration as well as maternal and perinatal outcomes associated with the observed differences in CD rates. CONCLUSIONS In this study, we found that several factors not included in the Robson classification explain a significant proportion of the spatiotemporal difference in CD rates in some Robson groups. These findings suggest that incorporating these factors into explanatory models using the Robson classification may be useful for ensuring that public health initiatives regarding CD rates are evidence informed.
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Affiliation(s)
- Giulia M. Muraca
- Clinical Epidemiology Unit, Department of Medicine, Solna, Karolinska University Hospital, Karolinska Institutet, Eugeniahemmet, Stockholm, Sweden
- Department of Obstetrics and Gynaecology, University of British Columbia and the Children’s and Women’s Hospital and Health Centre of British Columbia, Vancouver, British Columbia, Canada
- Departments of Obstetrics and Gynecology and Health Research Methods, Evidence & Impact, Faculty of Health Sciences, McMaster University, Ontario, Canada
- * E-mail:
| | - K.S. Joseph
- Department of Obstetrics and Gynaecology, University of British Columbia and the Children’s and Women’s Hospital and Health Centre of British Columbia, Vancouver, British Columbia, Canada
- School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada
| | - Neda Razaz
- Clinical Epidemiology Unit, Department of Medicine, Solna, Karolinska University Hospital, Karolinska Institutet, Eugeniahemmet, Stockholm, Sweden
| | - Linnea V. Ladfors
- Clinical Epidemiology Unit, Department of Medicine, Solna, Karolinska University Hospital, Karolinska Institutet, Eugeniahemmet, Stockholm, Sweden
| | - Sarka Lisonkova
- Department of Obstetrics and Gynaecology, University of British Columbia and the Children’s and Women’s Hospital and Health Centre of British Columbia, Vancouver, British Columbia, Canada
- School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada
| | - Olof Stephansson
- Clinical Epidemiology Unit, Department of Medicine, Solna, Karolinska University Hospital, Karolinska Institutet, Eugeniahemmet, Stockholm, Sweden
- Division of Women’s Health, Department of Obstetrics, Karolinska University Hospital, Stockholm, Sweden
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5
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Pulvermacher C, Van de Vondel P, Gerzen L, Gembruch U, Welchowski T, Schmid M, Merz WM. Analysis of cesarean section rates in two German hospitals applying the 10-Group Classification System. J Perinat Med 2021; 49:818-829. [PMID: 33827151 DOI: 10.1515/jpm-2020-0505] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2020] [Accepted: 03/18/2021] [Indexed: 11/15/2022]
Abstract
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.
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Affiliation(s)
| | | | - Lydia Gerzen
- Department of Obstetrics and Prenatal Medicine, University Hospital Bonn, Bonn, Germany
| | - Ulrich Gembruch
- Department of Obstetrics and Prenatal Medicine, University Hospital Bonn, Bonn, Germany
| | - Thomas Welchowski
- Department of Medical Biometry, Informatics and Epidemiology, Faculty of Medicine, University of Bonn, Bonn, Germany
| | - Matthias Schmid
- Department of Medical Biometry, Informatics and Epidemiology, Faculty of Medicine, University of Bonn, Bonn, Germany
| | - Waltraut M Merz
- Department of Obstetrics and Prenatal Medicine, University Hospital Bonn, Bonn, Germany
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Quibel T, Rozenberg P, Bouyer C, Bouyer J. Variation between hospital caesarean delivery rates when Robson's classification is considered: An observational study from a French perinatal network. PLoS One 2021; 16:e0251141. [PMID: 34415907 PMCID: PMC8378683 DOI: 10.1371/journal.pone.0251141] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2020] [Accepted: 04/20/2021] [Indexed: 11/18/2022] Open
Abstract
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.
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Affiliation(s)
- Thibaud Quibel
- Department of Gynecology and Obstetrics, Intercommunal Hospital Centre of Poissy-Saint-Germain-en-Laye, Poissy, France
- EA 7285, Research Unit "Risk and Safety in Clinical Medicine for Women and Perinatal Health", Versailles-Saint-Quentin University (UVSQ), Montigny-le-Bretonneux, France
| | - Patrick Rozenberg
- Department of Gynecology and Obstetrics, Intercommunal Hospital Centre of Poissy-Saint-Germain-en-Laye, Poissy, France
- EA 7285, Research Unit "Risk and Safety in Clinical Medicine for Women and Perinatal Health", Versailles-Saint-Quentin University (UVSQ), Montigny-le-Bretonneux, France
| | - Camille Bouyer
- Department of Gynecology and Obstetrics, Intercommunal Hospital Centre of Poissy-Saint-Germain-en-Laye, Poissy, France
- Réseau de Périnatalité Maternité en Yvelines et Périnatalité Active (MYPA), Saint-Germain-en-Laye, France
| | - Jean Bouyer
- Université Paris-Saclay, UVSQ, Inserm, CESP, Villejuif, France
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Do obstetrics trainees working hours affect caesarean section rates in normal risk women? Eur J Obstet Gynecol Reprod Biol 2021; 258:358-361. [PMID: 33535147 DOI: 10.1016/j.ejogrb.2021.01.036] [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: 12/06/2020] [Revised: 01/17/2021] [Accepted: 01/20/2021] [Indexed: 11/20/2022]
Abstract
OBJECTIVES The rate of caesarean section (CS) is increasing globally. The nulliparous, term, singleton, vertex presentation, spontaneously labouring woman (Robson Group 1/RG1) is considered low risk for CS. It has been hypothesized that more CS occur at nighttime or at weekends due to doctor fatigue. The European Working Time Directive (EWTD) was implemented in our institution in 2013 to limit doctor working hours, which aimed at reducing fatigue but arguably fractures continuity of care. This study aimed to determine the effect of nocturnal hours and weekend on-call as well as the implementation of EWTD on our RG1 CS rates. STUDY DESIGN This was a population-based study in a tertiary referral centre from 2008-2017. The inclusion criteria for our study were limited to RG1. Data were analysed from an established clinical database, including mode and time of delivery. Descriptive statistics are presented as number and percent for categorical variables. Relative frequencies were tested using chi-squared test. All statistical analyses were performed using SPSS Version 26. Statistical significance was defined as p < .05. RESULTS There were 86,473 deliveries over the 10-year study period. There were 18,761 women in RG1. Overall the RG1 CS rate was 12.9 % (n = 2415). Rates of CS in the RG1 were not statistically different between those delivering on weekdays (12.9 %, n = 1726/13,430) and weekends (12.9 %, n = 689/5,331, OR 0.99, 95 % CI = 0.90-1.09, p = .89). During daytime hours the CS rate was 12.1 % (n = 777/6411) and at nighttime was 13.3 % (n = 1638/12,350, OR 1.10, 95 % CI = 1.01-1.21, p = .03). Comparing the time periods pre and post EWTD implementation, there was a significant increase in CS rates (12.1 % n = 1319/10,873 V 13.9 % n = 1096/7,888, OR 1.17, 95 % CI = 1.07-1.27 p < .001). With respect to other modes of delivery in RG1 pre and post EWTD, there was a statistically significant decrease in operative vaginal delivery (OVD) rates (40.1%, n=4,360 V 37.7%, n=2,973, OR 0.90, 95% CI = 0.85-0.95, p = .001) CONCLUSION: This study shows an association between obstetric trainee working practices, RG1 CS and OVD rates; this is most pronounced at night and after the introduction of the EWTD. It is unlikely that obstetric trainee working practices are the only factor related to the increasing CS rate and reduced OVD rate. Consideration should be giving to addressing the needs of obstetric trainees in relation to achieving their competencies with now reduced labour ward exposure. Further study is required to see if alternate arrangements in relation to simulation training could increase the OVD rate and reduce the CS rate.
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Laurita Longo V, Odjidja EN, Beia TK, Neri M, Kielmann K, Gittardi I, Di Rosa AI, Boldrini M, Melis GB, Scambia G, Lanzone A. "An unnecessary cut?" multilevel health systems analysis of drivers of caesarean sections rates in Italy: a systematic review. BMC Pregnancy Childbirth 2020; 20:770. [PMID: 33302920 PMCID: PMC7731545 DOI: 10.1186/s12884-020-03462-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Accepted: 11/26/2020] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Improvements in medical technologies have seen over-medicalization of childbirth. Caesarean section (CS) is a lifesaving procedure proven effective in reducing maternal and perinatal mortality across the globe. However, as with any medical procedure, the CS intrinsically carries some risk to its beneficiaries. In recent years, CS rates have risen alarmingly in high-income countries. Many exceeding the World Health Organisation (WHO) recommendation of a 10 to 15% annual CS rate. While this situation poses an increased risk to women and their children, it also represents an excess human and financial burden on health systems. Therefore, from a health system perspective this study systematically summarizes existing evidence relevant to the factors driving the phenomenon of increasing CS rates using Italy as a case study. METHODS Employing the WHO Health System Framework (WHOHSF), this systematic review used the PRISMA guidelines to report findings. PubMed, SCOPUS, MEDLINE, Cochrane Library and Google Scholar databases were searched up until April 1, 2020. Findings were organised through the six dimensions of the WHOHSF framework: service delivery, health workforce, health system information; medical products vaccine and technologies, financing; and leadership and governance. RESULTS CS rates in Italy are affected by complex interactions among several stakeholder groups and contextual factors such as the hyper-medicalisation of delivery, differences in policy and practice across units and the national context, issues pertaining to the legal and social environment, and women's attitudes towards pregnancy and childbirth. CONCLUSION Mitigating the high rates of CS will require a synergistic multi-stakeholder intervention. Specifically, with processes able to attract the official endorsement of policy makers, encourage concensus between regional authorities and local governments and guide the systematic compliance of delivery units with its clinical guidelines.
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Affiliation(s)
- Valentina Laurita Longo
- Department of Surgical Sciences, Department of Obstetrics and Gynaecology, University of Cagliari, SS 554 - bivio Sestu, Monserrato, 09032, Cagliari, Italy.
- Queen Margaret University, Institute for Global Health and Development, Edinburgh, EH21 6UU, Scotland, UK.
- Catholic University of Sacred Heart, 00168, Rome, Italy.
| | - Emmanuel Nene Odjidja
- Queen Margaret University, Institute for Global Health and Development, Edinburgh, EH21 6UU, Scotland, UK
| | - Thierry Kamba Beia
- Queen Margaret University, Institute for Global Health and Development, Edinburgh, EH21 6UU, Scotland, UK
- Health Services Department, Copperbelt University, Kitwe, Zambia
| | - Manuela Neri
- Department of Surgical Sciences, Department of Obstetrics and Gynaecology, University of Cagliari, SS 554 - bivio Sestu, Monserrato, 09032, Cagliari, Italy
| | - Karina Kielmann
- Queen Margaret University, Institute for Global Health and Development, Edinburgh, EH21 6UU, Scotland, UK
| | - Irene Gittardi
- Legal Department "Luca Santa Maria e associati", Via G. Serbelloni 1, 20122, Milan, Italy
| | - Amanda Isabella Di Rosa
- Queen Margaret University, Institute for Global Health and Development, Edinburgh, EH21 6UU, Scotland, UK
| | - Michela Boldrini
- Department of Economics, University of Bologna, Piazza Antonio Scaravilli 2, 40126, Bologna, Italy
| | - Gian Benedetto Melis
- Department of Surgical Sciences, Department of Obstetrics and Gynaecology, University of Cagliari, SS 554 - bivio Sestu, Monserrato, 09032, Cagliari, Italy
| | - Giovanni Scambia
- Catholic University of Sacred Heart, 00168, Rome, Italy
- Fondazione Policlinico Universitario Agostino Gemelli, IRCCS, Largo Agostino Gemelli 8, 00168, Rome, Italy
| | - Antonio Lanzone
- Catholic University of Sacred Heart, 00168, Rome, Italy
- Fondazione Policlinico Universitario Agostino Gemelli, IRCCS, Largo Agostino Gemelli 8, 00168, Rome, Italy
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9
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Triep K, Torbica N, Raio L, Surbek D, Endrich O. The Robson classification for caesarean section-A proposed method based on routinely collected health data. PLoS One 2020; 15:e0242736. [PMID: 33253262 PMCID: PMC7703923 DOI: 10.1371/journal.pone.0242736] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2020] [Accepted: 11/06/2020] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND With an increasing rate of caesarean sections as well as rising numbers of multiple pregnancies, valid classifications for benchmarking are needed. The Robson classification provides a method to group cases with caesarean section in order to assess differences in outcome across regions and sites. In this study we set up a novel method of classification by using routinely collected health data. We hypothesize i that routinely collected health data can be used to apply complex medical classifications and ii that the Robson classification is capable of classifying mothers and their corresponding newborn into meaningful groups with regard to outcome. METHODS AND FINDINGS The study was conducted at the coding department and the department of obstetrics and gynecology Inselspital, University Hospital of Bern, Switzerland. The study population contained inpatient cases from 2014 until 2017. Administrative and health data were extracted from the Data Warehouse. Cases were classified by a Structured Query Language code according to the Robson criteria using data from the administrative system, the electronic health record and from the laboratory system. An automated query to classify the cases according to Robson could be implemented and successfully validated. A linkage of the mother's class to the corresponding newborn could be established. The distribution of clinical indicators was described. It could be shown that the Robson classes are associated to outcome parameters and case related costs. CONCLUSIONS With this study it could be demonstrated, that a complex query on routinely collected health data would serve for medical classification and monitoring of quality and outcome. Risk-stratification might be conducted using this data set and should be the next step in order to evaluate the Robson criteria and outcome. This study will enhance the discussion to adopt an automated classification on routinely collected health data for quality assurance purposes.
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Affiliation(s)
- Karen Triep
- Medical Directorate, Inselspital, University Hospital of Bern, Berne, Switzerland
| | - Nenad Torbica
- Medical Directorate, Inselspital, University Hospital of Bern, Berne, Switzerland
| | - Luigi Raio
- Department of Obstetrics and Gynecology, University Hospital of Bern, Berne, Switzerland
| | - Daniel Surbek
- Department of Obstetrics and Gynecology, University Hospital of Bern, Berne, Switzerland
| | - Olga Endrich
- Medical Directorate, Inselspital, University Hospital of Bern, Berne, Switzerland
- Insel Data Science Center IDSC, Inselspital, University Hospital of Bern, Berne, Switzerland
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10
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Vink MDH, de Bekker PJGM, Koolman X, van Tulder MW, de Vries R, Mol BWJ, van der Hijden EJE. Design characteristics of studies on medical practice variation of caesarean section rates: a scoping review. BMC Pregnancy Childbirth 2020; 20:478. [PMID: 32819308 PMCID: PMC7441547 DOI: 10.1186/s12884-020-03169-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Accepted: 08/11/2020] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Medical practice variation in caesarean section rates is the most studied type of practice variation in the field of obstetrics and gynaecology. This has not resulted in increased homogeneity of treatment between geographic areas or healthcare providers. Our study aim was to evaluate whether current study designs on medical practice variation of caesarean section rates were optimized to identify the unwarranted share of practice variation and could contribute to the reduction of unwarranted practice variation by meeting criteria for audit and feedback. METHODS We searched PubMed, Embase, EBSCO/CINAHL and Wiley/Cochrane Library from inception to March 24th, 2020. Studies that compared the rate of caesarean sections between individuals, institutions or geographic areas were included. Study design was assessed on: selection procedure of study population, data source, case-mix correction, patient preference, aggregation level of analysis, maternal and neonatal outcome, and determinants (professional and organizational characteristics). RESULTS A total of 284 studies were included. Most studies (64%) measured the caesarean section rate in the entire study population instead of using a sample (30%). (National) databases were most often used as information source (57%). Case-mix correction was performed in 87 studies (31%). The Robson classification was used in 20% of the studies following its endorsement by the WHO in 2015. The most common levels of aggregation were hospital level (35%) and grouped hospitals (35%) e.g. private versus public. The percentage of studies that assessed the relationship between variation in caesarean section rates and maternal outcome was 9%, neonatal outcome 19%, determinants (professional and organizational characteristics) 21% and patient preference 2%. CONCLUSIONS Study designs of practice variation in caesarean sections varied considerably, raising questions about their appropriateness. Studies focused on measuring practice variation, rather than contributing to the reduction of unwarranted practice variation. Future studies should correct for differences in patient characteristics (case-mix) and patient preference to identify unwarranted practice variation. Practice variation studies could be used for audit and feedback if results are presented at lower levels of aggregation, and appeal to intrinsic motivation of physicians, for example by including the health effects on mother and child.
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Affiliation(s)
- Maarten D H Vink
- Department Health Sciences, Faculty of Science & Talma Institute, Vrije Universiteit, De Boelelaan 1085, 1081 HV, Amsterdam, the Netherlands.
- Department of Obstetrics and Gynaecology, University Medical Center Groningen, Groningen, the Netherlands.
| | - Piet J G M de Bekker
- Department Health Sciences, Faculty of Science & Talma Institute, Vrije Universiteit, De Boelelaan 1085, 1081 HV, Amsterdam, the Netherlands
| | - Xander Koolman
- Department Health Sciences, Faculty of Science & Talma Institute, Vrije Universiteit, De Boelelaan 1085, 1081 HV, Amsterdam, the Netherlands
| | - Maurits W van Tulder
- Department Health Sciences, Faculty of Science & Talma Institute, Vrije Universiteit, De Boelelaan 1085, 1081 HV, Amsterdam, the Netherlands
| | - Ralph de Vries
- Medical Library, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Ben Willem J Mol
- Department of Obstetrics and Gynaecology, Monash University, Clayton, Victoria, Australia
| | - Eric J E van der Hijden
- Department Health Sciences, Faculty of Science & Talma Institute, Vrije Universiteit, De Boelelaan 1085, 1081 HV, Amsterdam, the Netherlands
- Zilveren Kruis Health Insurance, Leusden, The Netherlands
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11
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Triunfo S, Ferrazzani S, Draisci G, Zanfini BA, Scambia G, Lanzone A. 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. BMJ Open 2018; 8:e020011. [PMID: 29627812 PMCID: PMC5892744 DOI: 10.1136/bmjopen-2017-020011] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
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.
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Affiliation(s)
- Stefania Triunfo
- Department of Obstetrics and Gynaecology, Fondazione Policlinico Universitario ‘A. Gemelli’, Catholic University of Sacred Heart, Rome, Italy
| | - Sergio Ferrazzani
- Department of Obstetrics and Gynaecology, Fondazione Policlinico Universitario ‘A. Gemelli’, Catholic University of Sacred Heart, Rome, Italy
| | - Gaetano Draisci
- Department of Anaesthesiology and Intensive Care, Fondazione Policlinico Universitario ‘A. Gemelli’, Catholic University of Sacred Heart, Rome, Italy
| | - Bruno Antonio Zanfini
- Department of Anaesthesiology and Intensive Care, Fondazione Policlinico Universitario ‘A. Gemelli’, Catholic University of Sacred Heart, Rome, Italy
| | - Giovanni Scambia
- Department of Obstetrics and Gynaecology, Fondazione Policlinico Universitario ‘A. Gemelli’, Catholic University of Sacred Heart, Rome, Italy
| | - Antonio Lanzone
- Department of Obstetrics and Gynaecology, Fondazione Policlinico Universitario ‘A. Gemelli’, Catholic University of Sacred Heart, Rome, Italy
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12
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Zhang Y, Gu N, Wang Z, Zheng M, Hu Y, Dai Y. Use of the 10-Group Classification System to analyze how the population control policy change in China has affected cesarean delivery. Int J Gynaecol Obstet 2017; 138:158-163. [PMID: 28502115 DOI: 10.1002/ijgo.12210] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2016] [Revised: 03/25/2017] [Accepted: 05/10/2017] [Indexed: 11/05/2022]
Abstract
OBJECTIVE To analyze the initial effect following the relaxation of China's population control policy on the cesarean delivery (CD) rate using the 10-Group Classification System (TGCS). METHODS A retrospective study included all deliveries at a center in Nanjing, China, during 2014-2015. The deliveries were classified using the TGCS. The obstetric populations and the CD rates in each group were compared between 2014 and 2015. RESULTS Overall, 11 006 deliveries were analyzed. The overall CD rate increased from 28.3% (1623/5737) in 2014 to 33.8% (1782/5269) in 2015 (P<0.001). The largest contributor to the overall CD rate-accounting for approximately one-third of all CDs-were nulliparous women with a single cephalic term pregnancy and induced labor or prelabor CD (group 2); the CD rate in this group increased from 27.2% to 31.4%. Moreover, the proportion of women with a single cephalic term pregnancy with previous CD (group 5) steeply increased from 6.4% to 10.4% of all deliveries; the CD rate in this group during 2014-2015 was 76.6%. CONCLUSION With China ending its one-child policy, the characteristics of the obstetric population changed. Women with a single cephalic term pregnancy with previous CD were the largest contributor to the CD rate increase.
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Affiliation(s)
- Yihui Zhang
- Department of Obstetrics and Gynecology, Nanjing Drum Tower Hospital, Nanjing University Medical School, Nanjing, China
| | - Ning Gu
- Department of Obstetrics and Gynecology, Nanjing Drum Tower Hospital, Nanjing University Medical School, Nanjing, China
| | - Zhiqun Wang
- Department of Obstetrics and Gynecology, Nanjing Drum Tower Hospital, Nanjing University Medical School, Nanjing, China
| | - Mingming Zheng
- Department of Obstetrics and Gynecology, Nanjing Drum Tower Hospital, Nanjing University Medical School, Nanjing, China
| | - Yali Hu
- Department of Obstetrics and Gynecology, Nanjing Drum Tower Hospital, Nanjing University Medical School, Nanjing, China
| | - Yimin Dai
- Department of Obstetrics and Gynecology, Nanjing Drum Tower Hospital, Nanjing University Medical School, Nanjing, China
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13
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Mesterton J, Ladfors L, Ekenberg Abreu A, Lindgren P, Saltvedt S, Weichselbraun M, Amer-Wåhlin I. Case mix adjusted variation in cesarean section rate in Sweden. Acta Obstet Gynecol Scand 2017; 96:597-606. [DOI: 10.1111/aogs.13117] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2016] [Accepted: 02/13/2017] [Indexed: 11/26/2022]
Affiliation(s)
- Johan Mesterton
- Medical Management Center; Department of Learning, Informatics, Management and Ethics; Karolinska Institutet; Stockholm Sweden
- Ivbar Institute; Stockholm Sweden
| | - Lars Ladfors
- Institute of Clinical Sciences; Department of Obstetrics and Gynecology; Sahlgrenska University Hospital; Gothenburg Sweden
| | - Anna Ekenberg Abreu
- Department of Obstetrics and Gynecology; Akademiska Hospital; Uppsala Sweden
| | - Peter Lindgren
- Medical Management Center; Department of Learning, Informatics, Management and Ethics; Karolinska Institutet; Stockholm Sweden
| | - Sissel Saltvedt
- Department of Obstetrics and Gynecology; Karolinska University Hospital; Stockholm Sweden
| | - Marianne Weichselbraun
- Institute of Clinical Sciences; Department of Obstetrics and Gynecology; Sahlgrenska University Hospital; Gothenburg Sweden
| | - Isis Amer-Wåhlin
- Medical Management Center; Department of Learning, Informatics, Management and Ethics; Karolinska Institutet; Stockholm Sweden
- Department of Women's and Children's Health; Karolinska Institutet; Stockholm Sweden
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14
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Gerli S, Favilli A, Franchini D, De Giorgi M, Casucci P, Parazzini F. Is the Robson's classification system burdened by obstetric pathologies, maternal characteristics and assistential levels in comparing hospitals cesarean rates? A regional analysis of class 1 and 3. J Matern Fetal Neonatal Med 2017; 31:173-177. [PMID: 28056581 DOI: 10.1080/14767058.2017.1279142] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
OBJECTIVE To assess if maternal risk profile and Hospital assistential levels were able to influence the inter-Hospitals comparison in the class 1 and 3 of the "The Ten Group Classification System" (TGCS). METHODS A population-based analysis using data from Institutional data-base of an Italian Region was carried out. The 11 maternity wards were divided into two categories: second-level hospitals (SLH), and first-level hospitals (FLH). The recorded deliveries were classified according to the TGCS. To analyze if different maternal characteristics and the hospitals assistential level could influence the cesarean section (CS) risk, a multivariate analysis was done considering separately women in the TGCS class 1 and 3. RESULTS From January 2011 to December 2013 were recorded 19,987 deliveries. Of those 7,693 were in the TGCS class 1 and 4,919 in the class 3. The CS rates were 20.8% and 14.7% in class 1 (p < 0.0001) and 6.9% and 5.3% (p < 0.0230) in class 3, respectively in the FLH and SLH. The multivariate logistic regression showed that the FLH, older maternal age and gestational diabetes were independent risk factors for CS in groups 1 and 3. Obesity and gestational hypertension were also independent risk factors for group 1. CONCLUSIONS TGCS is a useful tool to analyze the incidence of CS in a single center but in comparing different Hospitals, maternal characteristics and different assistential levels should be considered as potential bias.
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Affiliation(s)
- Sandro Gerli
- a Department of Obstetrics and Gynecology , University of Perugia , S. Andrea delle Fratte , Perugia , Italy
| | - Alessandro Favilli
- a Department of Obstetrics and Gynecology , University of Perugia , S. Andrea delle Fratte , Perugia , Italy
| | | | | | - Paola Casucci
- c Regione Umbria , Direzione Regionale Salute , Perugia , Italy
| | - Fabio Parazzini
- d Dipartimento Materno Infantile, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico , Università di Milano , Milan , Italy.,e Dipartimento di Scienze Cliniche e di Comunità , Universita' di Milano , Milan , Italy
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15
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Souza JP, Betran AP, Dumont A, de Mucio B, Gibbs Pickens CM, Deneux-Tharaux C, Ortiz-Panozo E, Sullivan E, Ota E, Togoobaatar G, Carroli G, Knight H, Zhang J, Cecatti JG, Vogel JP, Jayaratne K, Leal MC, Gissler M, Morisaki N, Lack N, Oladapo OT, Tunçalp Ö, Lumbiganon P, Mori R, Quintana S, Costa Passos AD, Marcolin AC, Zongo A, Blondel B, Hernández B, Hogue CJ, Prunet C, Landman C, Ochir C, Cuesta C, Pileggi-Castro C, Walker D, Alves D, Abalos E, Moises E, Vieira EM, Duarte G, Perdona G, Gurol-Urganci I, Takahiko K, Moscovici L, Campodonico L, Oliveira-Ciabati L, Laopaiboon M, Danansuriya M, Nakamura-Pereira M, Costa ML, Torloni MR, Kramer MR, Borges P, Olkhanud PB, Pérez-Cuevas R, Agampodi SB, Mittal S, Serruya S, Bataglia V, Li Z, Temmerman M, Gülmezoglu AM. A global reference for caesarean section rates (C-Model): a multicountry cross-sectional study. BJOG 2015; 123:427-36. [PMID: 26259689 PMCID: PMC4873961 DOI: 10.1111/1471-0528.13509] [Citation(s) in RCA: 69] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/27/2015] [Indexed: 12/01/2022]
Abstract
Objective To generate a global reference for caesarean section (CS) rates at health facilities. Design Cross‐sectional study. Setting Health facilities from 43 countries. Population/Sample Thirty eight thousand three hundred and twenty‐four women giving birth from 22 countries for model building and 10 045 875 women giving birth from 43 countries for model testing. Methods We hypothesised that mathematical models could determine the relationship between clinical‐obstetric characteristics and CS. These models generated probabilities of CS that could be compared with the observed CS rates. We devised a three‐step approach to generate the global benchmark of CS rates at health facilities: creation of a multi‐country reference population, building mathematical models, and testing these models. Main outcome measures Area under the ROC curves, diagnostic odds ratio, expected CS rate, observed CS rate. Results According to the different versions of the model, areas under the ROC curves suggested a good discriminatory capacity of C‐Model, with summary estimates ranging from 0.832 to 0.844. The C‐Model was able to generate expected CS rates adjusted for the case‐mix of the obstetric population. We have also prepared an e‐calculator to facilitate use of C‐Model (www.who.int/reproductivehealth/publications/maternal_perinatal_health/c-model/en/). Conclusions This article describes the development of a global reference for CS rates. Based on maternal characteristics, this tool was able to generate an individualised expected CS rate for health facilities or groups of health facilities. With C‐Model, obstetric teams, health system managers, health facilities, health insurance companies, and governments can produce a customised reference CS rate for assessing use (and overuse) of CS. Tweetable abstract The C‐Model provides a customized benchmark for caesarean section rates in health facilities and systems. The C‐Model provides a customized benchmark for caesarean section rates in health facilities and systems.
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Affiliation(s)
- J P Souza
- Department of Social Medicine, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, SP, Brazil
| | - A P Betran
- Department of Reproductive Health and Research, UNDP-UNFPA-UNICEF-WHO World Bank Special Programme of Research, Development and Research Training in Human Reproduction, WHO, Geneva, Switzerland
| | - A Dumont
- Research Institute for Development, Université Paris Descartes, Sorbonne Paris Cité, UMR 216, Paris, France
| | - B de Mucio
- Latin American Center for Perinatology, Women and Reproductive Health, (CLAP/WR), WHO Regional Office for the Americas, Montevideo, Uruguay
| | - C M Gibbs Pickens
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - C Deneux-Tharaux
- Inserm U1153, Obstetrical, Perinatal and Pediatric Epidemiology Research Team, Center for Epidemiology and Biostatistics, Paris Descartes University, Paris, France
| | - E Ortiz-Panozo
- Center for Population Health Research, National Institute of Public Health, Cuernavaca, Mexico
| | - E Sullivan
- Faculty of Health, University of Technology, Sydney, NSW, Australia
| | - E Ota
- Department of Health Policy, National Center for Child Health and Development, Tokyo, Japan
| | - G Togoobaatar
- Department of Health Policy, National Center for Child Health and Development, Tokyo, Japan
| | - G Carroli
- Centro Rosarino de Estudios Perinatales, Rosario, Argentina
| | - H Knight
- Royal College of Obstetricians and Gynaecologists, Office for Research and Clinical Audit, Lindsay Stewart R&D Centre, London, UK.,Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - J Zhang
- Ministry of Education-Shanghai Key Laboratory of Children's Environmental Health, Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - J G Cecatti
- Department of Obstetrics and Gynaecology, School of Medical Sciences, University of Campinas (UNICAMP), Campinas, SP, Brazil
| | - J P Vogel
- Department of Reproductive Health and Research, UNDP-UNFPA-UNICEF-WHO World Bank Special Programme of Research, Development and Research Training in Human Reproduction, WHO, Geneva, Switzerland
| | - K Jayaratne
- Family Health Bureau, Ministry of Health, Colombo, Sri Lanka
| | - M C Leal
- Escola Nacional de Saúde Pública (ENSP), Fundação Oswaldo Cruz (FIOCRUZ), Rio de Janeiro, Brazil
| | - M Gissler
- National Institute for Health and Welfare, Helsinki, Finland
| | - N Morisaki
- Department of Health Policy, National Center for Child Health and Development, Tokyo, Japan.,Department of Paediatrics, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - N Lack
- Bayerische Arbeitsgemeinschaft für Qualitätssicherung in der Stationären Versorgung (BAQ), Bayerische Krankenhausgesellschaft, Munich, Germany
| | - O T Oladapo
- Department of Reproductive Health and Research, UNDP-UNFPA-UNICEF-WHO World Bank Special Programme of Research, Development and Research Training in Human Reproduction, WHO, Geneva, Switzerland
| | - Ö Tunçalp
- Department of Reproductive Health and Research, UNDP-UNFPA-UNICEF-WHO World Bank Special Programme of Research, Development and Research Training in Human Reproduction, WHO, Geneva, Switzerland
| | - P Lumbiganon
- Department of Obstetrics and Gynecology, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | - R Mori
- Department of Health Policy, National Center for Child Health and Development, Tokyo, Japan
| | - S Quintana
- Department of Gynaecology and Obstetrics, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, SP, Brazil
| | - A D Costa Passos
- Department of Social Medicine, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, SP, Brazil
| | - A C Marcolin
- Department of Gynaecology and Obstetrics, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, SP, Brazil
| | - A Zongo
- Research Institute for Development, Université Paris Descartes, Sorbonne Paris Cité, UMR 216, Paris, France.,Direction de la santé de la famille, Ministère de la Santé, Ouagadougou, Burkina Faso
| | - B Blondel
- Inserm U1153, Obstetrical, Perinatal and Pediatric Epidemiology Research Team, Center for Epidemiology and Biostatistics, Paris Descartes University, Paris, France
| | - B Hernández
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - C J Hogue
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - C Prunet
- Inserm U1153, Obstetrical, Perinatal and Pediatric Epidemiology Research Team, Center for Epidemiology and Biostatistics, Paris Descartes University, Paris, France
| | - C Landman
- Escola Nacional de Saúde Pública (ENSP), Fundação Oswaldo Cruz (FIOCRUZ), Rio de Janeiro, Brazil
| | - C Ochir
- School of Public Health, Health Sciences University of Mongolia, Ulaanbaatar, Mongolia
| | - C Cuesta
- Centro Rosarino de Estudios Perinatales, Rosario, Argentina
| | - C Pileggi-Castro
- GLIDE Technical Cooperation and Research, Ribeirão Preto, SP, Brazil.,Department of Paediatrics, Ribeirão Preto Medical School, University of Sao Paulo, Ribeirão Preto, SP, Brazil
| | - D Walker
- Departments of Obstetrics & Gynaecology and Global Health Sciences, University of California, San Francisco, CA, USA
| | - D Alves
- Department of Social Medicine, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, SP, Brazil
| | - E Abalos
- Centro Rosarino de Estudios Perinatales, Rosario, Argentina
| | - Ecd Moises
- Department of Gynaecology and Obstetrics, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, SP, Brazil
| | - E M Vieira
- Department of Social Medicine, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, SP, Brazil
| | - G Duarte
- Department of Gynaecology and Obstetrics, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, SP, Brazil
| | - G Perdona
- Department of Social Medicine, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, SP, Brazil
| | - I Gurol-Urganci
- Royal College of Obstetricians and Gynaecologists, Office for Research and Clinical Audit, Lindsay Stewart R&D Centre, London, UK.,Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - K Takahiko
- Department of Health Policy, National Center for Child Health and Development, Tokyo, Japan
| | - L Moscovici
- Department of Social Medicine, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, SP, Brazil.,GLIDE Technical Cooperation and Research, Ribeirão Preto, SP, Brazil
| | - L Campodonico
- Centro Rosarino de Estudios Perinatales, Rosario, Argentina
| | - L Oliveira-Ciabati
- Department of Social Medicine, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, SP, Brazil.,GLIDE Technical Cooperation and Research, Ribeirão Preto, SP, Brazil
| | - M Laopaiboon
- Department of Biostatistics and Demography, Faculty of Public Health, Khon Kaen University, Khon Kaen, Thailand
| | - M Danansuriya
- Family Health Bureau, Ministry of Health, Colombo, Sri Lanka
| | - M Nakamura-Pereira
- Escola Nacional de Saúde Pública (ENSP), Fundação Oswaldo Cruz (FIOCRUZ), Rio de Janeiro, Brazil
| | - M L Costa
- Department of Obstetrics and Gynaecology, School of Medical Sciences, University of Campinas (UNICAMP), Campinas, SP, Brazil
| | - M R Torloni
- Department of Obstetrics, School of Medicine of São Paulo, São Paulo Federal University, São Paulo, Brazil
| | - M R Kramer
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - P Borges
- Escola Nacional de Saúde Pública (ENSP), Fundação Oswaldo Cruz (FIOCRUZ), Rio de Janeiro, Brazil
| | - P B Olkhanud
- School of Public Health, Health Sciences University of Mongolia, Ulaanbaatar, Mongolia
| | - R Pérez-Cuevas
- Social Protection and Health Division, Inter-American Development Bank, Mexico City, Mexico
| | - S B Agampodi
- Family Health Bureau, Ministry of Health, Colombo, Sri Lanka
| | - S Mittal
- Fortis Memorial Research Institute, Gurgaon, Haryana, India
| | - S Serruya
- Latin American Center for Perinatology, Women and Reproductive Health, (CLAP/WR), WHO Regional Office for the Americas, Montevideo, Uruguay
| | - V Bataglia
- Hospital Nacional de Itauguá, Itauguá, Paraguay
| | - Z Li
- Faculty of Health, University of Technology, Sydney, NSW, Australia
| | - M Temmerman
- Department of Reproductive Health and Research, UNDP-UNFPA-UNICEF-WHO World Bank Special Programme of Research, Development and Research Training in Human Reproduction, WHO, Geneva, Switzerland
| | - A M Gülmezoglu
- Department of Reproductive Health and Research, UNDP-UNFPA-UNICEF-WHO World Bank Special Programme of Research, Development and Research Training in Human Reproduction, WHO, Geneva, Switzerland
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16
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Triunfo S, Ferrazzani S, Lanzone A, Scambia G. Identification of obstetric targets for reducing cesarean section rate using the Robson Ten Group Classification in a tertiary level hospital. Eur J Obstet Gynecol Reprod Biol 2015; 189:91-5. [DOI: 10.1016/j.ejogrb.2015.03.030] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2014] [Revised: 03/24/2015] [Accepted: 03/31/2015] [Indexed: 11/26/2022]
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17
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Ferreira EC, Pacagnella RC, Costa ML, Cecatti JG. The Robson ten-group classification system for appraising deliveries at a tertiary referral hospital in Brazil. Int J Gynaecol Obstet 2015; 129:236-9. [PMID: 25704253 DOI: 10.1016/j.ijgo.2014.11.026] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2014] [Revised: 11/25/2014] [Accepted: 02/02/2015] [Indexed: 10/24/2022]
Abstract
OBJECTIVE To evaluate the distribution of women according to the Robson 10-group classification system (RTGCS) and the occurrence of severe maternal morbidity (SMM) by mode of delivery at a tertiary referral hospital. METHODS A retrospective cross-sectional study was conducted of all women admitted to the Women's Hospital at the University of Campinas (Campinas, Brazil) for delivery between January 2009 and July 2013. Women were grouped according to RTGCS. Mode of delivery and SMM (defined as need for admission to the intensive care unit) were assessed. RESULTS Among 12 771 women, 5957 (46.6%) delivered by cesarean. Overall, 3594 (28.1%) women were in group 1 (nulliparous, single pregnancy, cephalic, term, spontaneous labor), 2328 (18.2%) in group 5 (≥1 previous cesarean, single pregnancy, cephalic, term), and 2112 (16.5%) in group 3 (multiparous excluding previous cesarean, single pregnancy, cephalic, term, spontaneous labor). Group 5 contributed the most cesarean deliveries (1626 [27.3%]), followed by group 2 (nulliparous, single pregnancy, cephalic, term, induced labor or cesarean before labor; 1049 [17.6%]). SMM was more common among women undergoing cesarean delivery than among those delivering vaginally in groups 1-5. CONCLUSION The RTGCS allowed the identification of groups with the highest frequency of cesarean delivery and an assessment of SMM. This should be considered in related health policies.
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Affiliation(s)
- Elton C Ferreira
- Department of Obstetrics and Gynecology, School of Medical Sciences, University of Campinas, Campinas, Brazil
| | - Rodolfo C Pacagnella
- Department of Obstetrics and Gynecology, School of Medical Sciences, University of Campinas, Campinas, Brazil
| | - Maria L Costa
- Department of Obstetrics and Gynecology, School of Medical Sciences, University of Campinas, Campinas, Brazil
| | - Jose G Cecatti
- Department of Obstetrics and Gynecology, School of Medical Sciences, University of Campinas, Campinas, Brazil.
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18
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Nippita TA, Lee YY, Patterson JA, Ford JB, Morris JM, Nicholl MC, Roberts CL. Variation in hospital caesarean section rates and obstetric outcomes among nulliparae at term: a population-based cohort study. BJOG 2015; 122:702-11. [DOI: 10.1111/1471-0528.13281] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/26/2014] [Indexed: 11/27/2022]
Affiliation(s)
- TA Nippita
- Clinical and Population Perinatal Health Research; Kolling Institute; Northern Sydney Local Health District; St Leonards NSW Australia
- Sydney Medical School Northern; University of Sydney; St Leonards NSW Australia
- Department of Obstetrics and Gynaecology; Royal North Shore Hospital; Northern Sydney Local Health District; St Leonards NSW Australia
| | - YY Lee
- Clinical and Population Perinatal Health Research; Kolling Institute; Northern Sydney Local Health District; St Leonards NSW Australia
| | - JA Patterson
- Clinical and Population Perinatal Health Research; Kolling Institute; Northern Sydney Local Health District; St Leonards NSW Australia
| | - JB Ford
- Clinical and Population Perinatal Health Research; Kolling Institute; Northern Sydney Local Health District; St Leonards NSW Australia
| | - JM Morris
- Clinical and Population Perinatal Health Research; Kolling Institute; Northern Sydney Local Health District; St Leonards NSW Australia
- Sydney Medical School Northern; University of Sydney; St Leonards NSW Australia
| | - MC Nicholl
- Sydney Medical School Northern; University of Sydney; St Leonards NSW Australia
- Department of Obstetrics and Gynaecology; Royal North Shore Hospital; Northern Sydney Local Health District; St Leonards NSW Australia
| | - CL Roberts
- Clinical and Population Perinatal Health Research; Kolling Institute; Northern Sydney Local Health District; St Leonards NSW Australia
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Di Martino M, Fusco D, Colais P, Pinnarelli L, Davoli M, Perucci CA. Differential misclassification of confounders in comparative evaluation of hospital care quality: caesarean sections in Italy. BMC Public Health 2014; 14:1049. [PMID: 25297561 PMCID: PMC4210510 DOI: 10.1186/1471-2458-14-1049] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2013] [Accepted: 09/29/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Despite extensive studies on exposure and disease misclassification, few studies have investigated misclassification of confounders. This study aimed to identify differentially misclassified confounders in a comparative evaluation of hospital care quality and to quantify their impact on hospital-specific risk-adjusted estimates, focusing on the appropriateness of caesarean sections (CS). METHODS We gathered data from the Hospital Information System in Italy for women admitted in 2005-2010. We estimated adjusted proportions of CS with logistic regression models. Among several confounders, we focused on high fetal head at term (HFH), which is seldom objectively documentable in medical records. RESULTS A total of 540 maternity units were compared. The median HFH prevalence was 0.9%, ranging from 0 to 70%. In some units, HFH was coded so frequently that it was unlikely to reflect a natural heterogeneity. This "over-coding" was conditional on the outcome because it occurred more frequently for women that underwent CS. This suggested an opportunistic coding to justify the choice of a CS. HFH misclassification was not randomly distributed over Italy; it had an excess in the Campania region where, in some units, the proportion of HFHs gradually increased from 2005 to 2010 (e.g., from 0 to 26%), but the national average remained constant (2.5%). The inclusion of the misclassified diagnosis in the models favored those hospitals that codified in a less-than-fair manner. CONCLUSIONS Our findings emphasized the importance of rigorously inspecting for differential misclassification of confounders. Their validity may be subject to substantial heterogeneity over hospitals, over time and geographical areas.
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Affiliation(s)
- Mirko Di Martino
- />Department of Epidemiology, Regional Health Service, Lazio Region, Via di Santa Costanza, 53-00198 Rome, Italy
| | - Danilo Fusco
- />Department of Epidemiology, Regional Health Service, Lazio Region, Via di Santa Costanza, 53-00198 Rome, Italy
| | - Paola Colais
- />Department of Epidemiology, Regional Health Service, Lazio Region, Via di Santa Costanza, 53-00198 Rome, Italy
| | - Luigi Pinnarelli
- />Department of Epidemiology, Regional Health Service, Lazio Region, Via di Santa Costanza, 53-00198 Rome, Italy
| | - Marina Davoli
- />Department of Epidemiology, Regional Health Service, Lazio Region, Via di Santa Costanza, 53-00198 Rome, Italy
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Stivanello E, Rucci P, Lenzi J, Fantini MP. Determinants of cesarean delivery: a classification tree analysis. BMC Pregnancy Childbirth 2014; 14:215. [PMID: 24973937 PMCID: PMC4090181 DOI: 10.1186/1471-2393-14-215] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2014] [Accepted: 06/20/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Cesarean delivery (CD) rates are rising in many parts of the world. To define strategies to reduce them, it is important to identify their clinical and organizational determinants. The objective of this cross-sectional study is to identify sub-types of women at higher risk of CD using demographic, clinical and organizational variables. METHODS All hospital discharge records of women who delivered between 2005 and mid-2010 in the Emilia-Romagna Region of Italy were retrieved and linked with birth certificates. Sociodemographic and clinical information was retrieved from the two data sources. Organizational variables included activity volume (number of births per year), hospital type, and hour and day of delivery. A classification tree analysis was used to identify the variables and the combinations of variables that best discriminated cesarean from vaginal delivery. RESULTS The classification tree analysis indicated that the most important variables discriminating the sub-groups of women at different risk of cesarean section were: previous cesarean, mal-position/mal-presentation, fetal distress, and abruptio placentae or placenta previa or ante-partum hemorrhage. These variables account for more than 60% of all cesarean deliveries. A sensitivity analysis identified multiparity and fetal weight as additional discriminatory variables. CONCLUSIONS Clinical variables are important predictors of CD. To reduce the CD rate, audit activities should examine in more detail the clinical conditions for which the need of CD is questionable or inappropriate.
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Affiliation(s)
- Elisa Stivanello
- Department of Biomedical and Neuromotor Sciences, Alma Mater Studiorum – University of Bologna, Via San Giacomo 12, 40126 Bologna, Italy
| | - Paola Rucci
- Department of Biomedical and Neuromotor Sciences, Alma Mater Studiorum – University of Bologna, Via San Giacomo 12, 40126 Bologna, Italy
| | - Jacopo Lenzi
- Department of Biomedical and Neuromotor Sciences, Alma Mater Studiorum – University of Bologna, Via San Giacomo 12, 40126 Bologna, Italy
| | - Maria Pia Fantini
- Department of Biomedical and Neuromotor Sciences, Alma Mater Studiorum – University of Bologna, Via San Giacomo 12, 40126 Bologna, Italy
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Betrán AP, Vindevoghel N, Souza JP, Gülmezoglu AM, Torloni MR. A systematic review of the Robson classification for caesarean section: what works, doesn't work and how to improve it. PLoS One 2014; 9:e97769. [PMID: 24892928 PMCID: PMC4043665 DOI: 10.1371/journal.pone.0097769] [Citation(s) in RCA: 123] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2014] [Accepted: 04/24/2014] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Caesarean sections (CS) rates continue to increase worldwide without a clear understanding of the main drivers and consequences. The lack of a standardized internationally-accepted classification system to monitor and compare CS rates is one of the barriers to a better understanding of this trend. The Robson's 10-group classification is based on simple obstetrical parameters (parity, previous CS, gestational age, onset of labour, fetal presentation and number of fetuses) and does not involve the indication for CS. This classification has become very popular over the last years in many countries. We conducted a systematic review to synthesize the experience of users on the implementation of this classification and proposed adaptations. METHODS Four electronic databases were searched. A three-step thematic synthesis approach and a qualitative metasummary method were used. RESULTS 232 unique reports were identified, 97 were selected for full-text evaluation and 73 were included. These publications reported on the use of Robson's classification in over 33 million women from 31 countries. According to users, the main strengths of the classification are its simplicity, robustness, reliability and flexibility. However, missing data, misclassification of women and lack of definition or consensus on core variables of the classification are challenges. To improve the classification for local use and to decrease heterogeneity within groups, several subdivisions in each of the 10 groups have been proposed. Group 5 (women with previous CS) received the largest number of suggestions. CONCLUSIONS The use of the Robson classification is increasing rapidly and spontaneously worldwide. Despite some limitations, this classification is easy to implement and interpret. Several suggested modifications could be useful to help facilities and countries as they work towards its implementation.
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Affiliation(s)
- Ana Pilar Betrán
- UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction, Department of Reproductive Health and Research, World Health Organization, Geneva, Switzerland
| | | | - Joao Paulo Souza
- Department of Social Medicine, Ribeirao Preto Medical School, University of São Paulo, Ribeirao Preto, SP, Brazil
| | - A. Metin Gülmezoglu
- UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction, Department of Reproductive Health and Research, World Health Organization, Geneva, Switzerland
| | - Maria Regina Torloni
- Brazilian Cochrane Centre, São Paulo, Brazil, and Department of Internal Medicine, São Paulo Federal University, São Paulo, Brazil
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Lee YYC, Roberts CL, Patterson JA, Simpson JM, Nicholl MC, Morris JM, Ford JB. Unexplained variation in hospital caesarean section rates. Med J Aust 2013; 199:348-53. [PMID: 23992192 DOI: 10.5694/mja13.10279] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2013] [Accepted: 07/10/2013] [Indexed: 11/17/2022]
Abstract
OBJECTIVES To assess recent hospital caesarean section (CS) rates in New South Wales, adjusted for case mix; to quantify the amount of variation that can be explained by case mix differences; and to examine the potential impact on the overall CS rate of reducing variation in practice. DESIGN AND SETTING Population-based record linkage study of births in 81 hospitals in New South Wales, 2009-2010, using the Robson classification to categorise births, and multilevel logistic regression to examine variation in hospital CS rates within Robson groups. MAIN OUTCOME MEASURES Hospital CS rates. RESULTS The overall CS rate was 30.9%, ranging from 11.8% to 47.4% (interquartile range, 23.9%-33.1%) among hospitals. The three groups contributing most to the overall CS rate all comprised women with a single cephalic pregnancy who gave birth at term, including: those who had had a previous CS (36.4% of all CSs); nulliparous women with an elective delivery (prelabour CS or labour induction, 23.4%); and nulliparous women with spontaneous labour (11.1%). After adjustment for case mix, marked unexplained variation in hospital CS rates persisted for: nulliparous women at term; women who had had a previous CS; multifetal pregnancies; and preterm births. If variation in practice was reduced for these risk-based groups by achieving the "best practice" rate, this would lower the overall rate by an absolute reduction of 3.6%, from 30.9% to 27.3%. CONCLUSION Understanding hospital heterogeneity in performing CS and implementing evidence-based practices may result in improved maternity care. We have identified five risk-based groups as priority targets for reducing practice variation in CS rates.
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Maso G, Alberico S, Monasta L, Ronfani L, Montico M, Businelli C, Soini V, Piccoli M, Gigli C, Domini D, Fiscella C, Casarsa S, Zompicchiatti C, De Agostinis M, D'Atri A, Mugittu R, La Valle S, Di Leonardo C, Adamo V, Smiroldo S, Frate GD, Olivuzzi M, Giove S, Parente M, Bassini D, Melazzini S, Guaschino S, De Seta F, Demarini S, Travan L, Marchesoni D, Rossi A, Simon G, Zicari S, Tamburlini G. The application of the Ten Group classification system (TGCS) in caesarean delivery case mix adjustment. A multicenter prospective study. PLoS One 2013; 8:e62364. [PMID: 23755097 PMCID: PMC3674002 DOI: 10.1371/journal.pone.0062364] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2013] [Accepted: 03/21/2013] [Indexed: 11/18/2022] Open
Abstract
Background Caesarean delivery (CD) rates are commonly used as an indicator of quality in obstetric care and risk adjustment evaluation is recommended to assess inter-institutional variations. The aim of this study was to evaluate whether the Ten Group classification system (TGCS) can be used in case-mix adjustment. Methods Standardized data on 15,255 deliveries from 11 different regional centers were prospectively collected. Crude Risk Ratios of CDs were calculated for each center. Two multiple logistic regression models were herein considered by using: Model 1- maternal (age, Body Mass Index), obstetric variables (gestational age, fetal presentation, single or multiple, previous scar, parity, neonatal birth weight) and presence of risk factors; Model 2- TGCS either with or without maternal characteristics and presence of risk factors. Receiver Operating Characteristic (ROC) curves of the multivariate logistic regression analyses were used to assess the diagnostic accuracy of each model. The null hypothesis that Areas under ROC Curve (AUC) were not different from each other was verified with a Chi Square test and post hoc pairwise comparisons by using a Bonferroni correction. Results Crude evaluation of CD rates showed all centers had significantly higher Risk Ratios than the referent. Both multiple logistic regression models reduced these variations. However the two methods ranked institutions differently: model 1 and model 2 (adjusted for TGCS) identified respectively nine and eight centers with significantly higher CD rates than the referent with slightly different AUCs (0.8758 and 0.8929 respectively). In the adjusted model for TGCS and maternal characteristics/presence of risk factors, three centers had CD rates similar to the referent with the best AUC (0.9024). Conclusions The TGCS might be considered as a reliable variable to adjust CD rates. The addition of maternal characteristics and risk factors to TGCS substantially increase the predictive discrimination of the risk adjusted model.
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Affiliation(s)
- Gianpaolo Maso
- Department of Obstetrics and Gynaecology, Institute for Maternal and Child Health, IRCCS Burlo Garofolo, Trieste, Italy.
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Robson M, Hartigan L, Murphy M. Methods of achieving and maintaining an appropriate caesarean section rate. Best Pract Res Clin Obstet Gynaecol 2012; 27:297-308. [PMID: 23127896 DOI: 10.1016/j.bpobgyn.2012.09.004] [Citation(s) in RCA: 112] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2012] [Accepted: 09/14/2012] [Indexed: 11/20/2022]
Abstract
Caesarean section rates continue to increase worldwide. The appropriate caesarean section rate remains a topic of debate among women and professionals. Evidence-based medicine has not provided an answer and depends on interpretation of the literature. Overall caesarean section rates are unhelpful, and caesarean section rates should not be judged in isolation from other outcomes and epidemiological characteristics. Better understanding of caesarean section rates, their consequences and their benefits will improve care, and enable learning between delivery units nationally and internationally. To achieve and maintain an appropriate caesarean section rate requires a Multidisciplinary Quality Assurance Programme in each delivery unit, recognising caesarean section rates as one of many factors that determine quality. Women will always choose the type of delivery that seems safest to them and their babies. Professionals need to monitor the quality of their practice continuously in a standardised way to ensure that women can make the right choice.
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Affiliation(s)
- Michael Robson
- National Maternity Hospital, Holles Street, Dublin 2, Ireland.
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