Caesarean Section in Peru: Analysis of Trends Using the Robson Classification System

Indications of Induction and Caesarean Sections Performed Using the Robson Classification in a University Hospital in Spain from 2010 to 2021

Background: The Robson Ten Group Classification System (RTGCS) enables the assessment, monitoring, and comparison of caesarean section rates both within healthcare facilities and between them, and the indications of caesarean sections (CS) performed in a maternity ward. The aims of the present study were to conduct an analysis to assess the levels and distribution of birth from a descriptive approach by CS in La Ribera University Hospital (Spain) between 2010-2021 using the Robson classification; to describe the indications for the induction of labour and the causes of caesarean sections performed; and to examine the association between the induction of labour and CS birth. Methods: A retrospective study between 1 January 2010 and 31 December 2021. All eligible women were classified according to the RTGCS to determine the absolute and relative contribution by each group to the overall CS rate. The odds ratio (OR) of the variables of interest was estimated by logistic regression. In an analysis of the subgroups, the level of significance was adjusted using the Bonferroni method. Results: 20,578 women gave birth during the study period, 19% of them by CS. In 33% of births, induction was performed, and the most common cause was the premature rupture of membranes. Group 2 (nulliparous with induced labour/elective CS before labour) accounted for the largest contribution to the overall rate of CS (31.5%) and showed an upward trend from 23.2% to 39.7% in the time series, increasing the CS rate by 6.7%. The leading cause of CS was suspected fetal distress, followed by induction failure. Conclusions: In our study, Robson Group 2 was identified as the main contributor to the hospital's overall CS rate. Determining the causes of induction and CS in a population sample classified using the RTGCS enables the identification of the groups with the greatest deviation from the optimal rate of CS and the establishment of improvement plans to reduce the overall rate of caesarean sections in the maternity unit.

Quantifying the childhood and adolescent overnutrition attributable to specific risk factors: The Young Lives Study in Peru

OBJECTIVE

Launching priority actions demand a comprehensive appraisal of the size effect that risk factors have on the burden of overweight and obesity. This study aimed to estimate the incidence of overweight and obesity among children and adolescents, with special emphasis on the role of specific risk factors.

MATERIALS AND METHODS

Secondary analysis of data from the younger cohort of the Young Lives Study in Peru (2002-2017). The outcomes were: overweight and obesity, defined by the World Health Organization standards; whereas the exposures included caesarean birth, physical activity levels, sodas and sugar-sweetened beverages consumption, snacks consumption, and maternal body mass index (BMI). We used multilevel Poisson regression models, considering the repetitive nature of data, to estimate incidence rate ratios (IRRs) and population attributable fractions (PAFs).

RESULTS

A total of 2052 children, mean age 1 (SD 0.4) year, and 50% girls, were enrolled at baseline. After 14 (SD 0.5) years of follow-up, the incidence of overweight and obesity were 7.9 (95% CI 7.6-8.2) and 2.2 (95% CI 2.0-2.4) per 100 person-year, respectively. Maternal BMI (IRRs 3.51; PAF 31.8%), low physical activity (IRR 1.64; PAF 27.4%), caesarean birth (IRR 1.63; PAF 11.4%), almost daily snack consumption (IRR 1.60; PAF 32.1%), and almost daily consumption of sweetened beverages (IRR 1.47; PAF 26.0%) increased the risk of developing obesity.

CONCLUSIONS

This study provides evidence on the risk of overweight and obesity attributable to diet habits, physical activity and the obesogenic niche among children and adolescents in Peru, which may guide the implementation of evidence-based interventions.

Parto por cesárea y su asociación con el síndrome obstructivo bronquial agudo en pacientes de 12 a 36 meses de edad

Objetivo. Identificar la asociación entre partos por cesárea y el Síndrome obstructivo bronquial agudo (SOBA) en pacientes de 12 a 36 meses de edad hospitalizados en el Hospital de Vitarte-MINSA durante el año 2017-2019. Material y métodos. Se realizó un estudio analítico, retrospectivo, de casos y controles. La población estudiada fueron los pacientes de 12-36 meses de edad hospitalizados durante el año 2017-2019, conformada por 306 niños siendo 102 casos y 204 controles (1:2). Los datos a estudiar se obtuvieron de la historia clínica donde se registró las siguientes variables: edad, sexo, cesárea, APGAR, edad gestacional, lactancia materna, vacunación, hacinamiento y número de hermanos. Resultados. La población de estudio estuvo conformada principalmente por niños de 1 año de edad (53,27%) de sexo femenino (52,29%). El parto por cesárea representó el 41,18% de los nacimientos y se asoció a la presencia de SOBA (OR=2,50; IC95%=1,51-4,15; p<0,001) en comparación con el parto vaginal. De mismo modo se encontró asociación entre lactancia materna exclusiva (OR=0,42; IC 95%=0,23-0,78; p=0,006), vacunación (OR=0,56; IC 95%=0,33-0,94; p=0,027) y hacinamiento (OR=1,77; IC 95%=1,04-3,01; p=0,034); sin embargo, no hubo diferencia estadística entre la edad (p=0,343; IC95%=0,62-1,18%), sexo (p=0,871; IC95%=0,42-1,29), edad gestacional (p=0,164; IC95%=0,71-1,06), APGAR (p=0,685; IC95%=0,73-1,23) y número de hermanos (p=0,357; IC95%=0,89-1,39). Conclusión. El parto por cesárea se encuentra asociado al desarrollo del SOBA. Presentando 2 veces mayor riesgo de padecerlo si se nace por cesárea, esto debido a que causa un deterioro del sistema inmune.

Flat trend of high caesarean section rates in Peru: A pooled analysis of 3,376,062 births from the national birth registry, 2012 to 2020

Background

Methods

Findings

Interpretation

Funding

Adverse pregnancy and perinatal outcomes in Latin America and the Caribbean: systematic review and meta-analysis

Objective.

To estimate the point prevalence and likely ranges of pregnancy-induced hypertension, pre-eclampsia, gestational diabetes, low birth weight and preterm delivery in Latin America and the Caribbean, and evaluate the heterogeneity of the estimates.

Methods.

We conducted a systematic review and meta-analysis of observational studies reporting the prevalence of maternal and perinatal adverse outcomes in populations in Latin American and the Caribbean published between 2000 and 2019 in English, Spanish, or Portuguese. We searched PubMed, Embase, and LILACS. We estimated the point prevalence and evaluated overall heterogeneity and, in sub-group analyses, heterogeneity by study design and level of bias.

Results.

Of 1087 records retrieved, 50 articles were included in the review: two on hypertensive disorders of pregnancy, 14 on pre-eclampsia, six on gestational diabetes, nine on low birth weight and 19 on preterm birth. No meta-analysis for hypertensive disorders of pregnancy could be done because of the small number of studies. Point prevalence estimates and 95% confidence intervals (CIs) for pre-eclampsia, gestational diabetes, low birth weight, and preterm birth were: 6.6% (95% CI: 4.9%, 8.6%), 8.5% (95% CI: 3.9%, 14.7%), 8.5% (95% CI: 7.2%, 9.8%), and 10.0% (95% CI: 8.0%, 12.0%), respectively. We observed substantial heterogeneity overall and by study design. No major differences in estimates were observed by level of bias.

Conclusions.

The results of this study provide updated estimates of some of the most prevalent adverse pregnancy and perinatal outcomes in Latin America and the Caribbean. They highlight that important heterogeneity exists in prevalence estimates, which may reflect the diversity of populations in the region.

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

INTRODUCTION

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

MATERIAL AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Geographic and socioeconomic inequalities in cesarean birth rates in Peru: A comparison between 2009 and 2018

BACKGROUND

There is a global concern about the high rates of cesarean birth (CB). This study aimed to investigate the geographic and socioeconomic inequalities in CB rates in the Peruvian population.

METHODS

We conducted a population-based study using the Peruvian Demographic and Family Health Surveys (ENDES, the Spanish acronym for Encuesta Demográfica y de Salud Familiar) between 2009 and 2018. ENDES reported data from births registered in the five years preceding survey execution. For the years 2009 (n = 10 289) and 2018 (n = 23 077), we calculated the weighted rates of CB among variables such as natural geographic domain (Coast, Andean, or Amazon), area of residence (rural or urban), wealth index quintile (quintile 1 is poorest, and quintile 5 is richest), and educational level. To assess inequalities, we calculated the concentration index (CIs), the slope index of inequality (SII), and the relative index of inequality (RII).

RESULTS

The CB rates by year were 21.4% (95% confidence interval [CI]: 20.0-22.9) in 2009 and 34.5% (95% CI: 33.4-35.5) in 2018. Women living in urban and coastal regions and with a higher education level had the highest CB rates. All the CIs were positive, reflecting a prowealthy inequality in CB rates, and both SII and RII were positive, indicating a gap between the use of cesarean in women in the higher wealth quintile compared with those in the lower quintile.

CONCLUSIONS

Cesarean birth rates have increased by 60% during the last decade in Peru. The richest wealth quintiles had the highest CB rates during the study years, which were well above global recommendations.

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.

Using the Robson classification to assess caesarean section rates in Brazil: an observational study of more than 24 million births from 2011 to 2017

BACKGROUND

Applying the Robson classification to all births in Brazil, the objectives of our study were to estimate the rates of caesarean section delivery, assess the extent to which caesarean sections were clinically indicated, and identify variation across socioeconomic groups.

METHODS

We conducted a population-based study using routine records of the Live Births Information System in Brazil from January 1, 2011, to December 31, 2017. We calculated the relative size of each Robson group; the caesarean section rate; and the contribution to the overall caesarean section rate. We categorised Brazilian municipalities using the Human Development Index to explore caesarean section rates further. We estimated the time trend in caesarean section rates.

RESULTS

The rate of caesarean sections was higher in older and more educated women. Prelabour caesarean sections accounted for more than 54 % of all caesarean deliveries. Women with a previous caesarean section (Group 5) made up the largest group (21.7 %). Groups 6-9, for whom caesarean sections would be indicated in most cases, all had caesarean section rates above 82 %, as did Group 5. The caesarean section rates were higher in municipalities with a higher HDI. The general Brazilian caesarean section rate remained stable during the study period.

CONCLUSIONS

Brazil is a country with one of the world's highest caesarean section rates. This nationwide population-based study provides the evidence needed to inform efforts to improve the provision of clinically indicated caesarean sections. Our results showed that caesarean section rates were lower among lower socioeconomic groups even when clinically indicated, suggesting sub-optimal access to surgical care.

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

INTRODUCTION

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Trends in Cesarean Delivery Rate after Cessation of the One-Child Policy in China

OBJECTIVE

We aimed to describe changes in cesarean delivery (CD) rates after the change of the one-child policy in China by using the Robson classification in a large Chinese population.

STUDY DESIGN

This retrospective cohort study included 91,015 women who delivered at ≥24 weeks of gestation at a large tertiary obstetric center in Shanghai, China from 2011 to 2016. We analyzed CD rate trend and CD contribution trend in each Robson group. Logistic regression was used to calculate the odds of CD while adjusting for confounding variables.

RESULTS

The overall CD rate decreased from 49.0% in 2011 to 40.6% in 2016. In nulliparous women with singleton cephalic term pregnancy and planned CD, the CD contribution rate was reduced significantly from 29.3% in 2011 to 16.4% in 2016 (p < 0.001). In multiparous with a scarred uterus, the CD contribution rate began to increase from 3.8% in 2011 to 9.1% in 2016 (p < 0.001). Compared with delivery in 2011, delivery in 2016 was associated with a 37% (adjusted odds ratio [aOR]: 0.63; 95% confidence interval [CI]: 0.60-0.66) reduction in CD. This reduction was observed in both nulliparous women with singleton cephalic term pregnancy (aOR: 0.57; 95% CI: 0.54-0.60), and multiparous women with singleton cephalic term pregnancy without scar (aOR: 0.41; 95% CI: 0.30-0.55).

CONCLUSION

The rate of cesarean delivery in our Chinese population has declined significantly in the past few years.

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

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

Cesarean delivery rates for overall and multiple pregnancies in Japan: A descriptive study using nationwide health insurance claims data

AIM

Due to the lack of national perinatal registries, population-wide descriptive statistics on cesarean deliveries in Japan are unknown. We aim to describe cesarean deliveries for overall and multiple pregnancies using the Japan National Database of health insurance claims.

METHODS

We calculated the national and prefectural cesarean delivery rates for overall and multiple pregnancies in 2014. We described maternal morbidities (e.g., blood transfusion) and the place and type of the institutions providing prenatal and perinatal care.

RESULTS

The national cesarean delivery rates were 18.6% overall and 82.7% for women with multiple pregnancies. Prefectural cesarean delivery rates for overall and multiple pregnancies varied from 12.5% to 24.2% and from 49.2% to 100%, respectively, showing a moderate positive correlation (r = 0.59, p < 0.001). Overall, 1.4% of cesarean patients received an allogeneic blood transfusion, compared to 3.2% for those with multiple pregnancies. In addition, 65.9% of overall cesarean deliveries occurred at hospitals with ≥20 beds, whereas 94.6% of cesarean patients with multiple pregnancies delivered at hospitals. Older patients were more likely to receive their cesarean section at a different institution than their first visit within the same prefecture, but trans-prefectural movement during pregnancy covered by health insurance was most frequent among those in their early thirties: 7.0% overall and 10.7% for multiple pregnancies.

CONCLUSIONS

The overall cesarean delivery rate in Japan was optimal, but the rate was high for multiple pregnancies, with large regional differences. Data on patient movement across institutions and areas would help to improve the perinatal care system.

Routine haemoglobin assay after uncomplicated caesarean sections

Introduction

This study designed to detect whether the routine haemoglobin (Hb) assay after uncomplicated caesarean section (CS) is necessary.

Material and methods

One hundred and twenty-two (122) women who delivered by uncomplicated elective CS were included in this observational study. Pre-operative investigations were performed according to the hospital protocol, including complete blood count, haemoglobin, prothrombin time, activated partial thromboplastin time, and liver and kidney function tests. After the uncomplicated elective CS, blood samples taken from participants immediately, 12, 24, 48 hours, and 1-week post-operative (PO) for haemoglobin assay. Student’s t-test was used to compare the pre-operative, and PO haemoglobins to detect whether or not the Hb assay after uncomplicated CSs is necessary.

Results

There was no significant difference between the pre-operative haemoglobin (11.6 ± 6.4 gms%), and the immediate PO haemoglobin (11.1 ± 5.9; p = 0.1 [95% CI: –1.05, 0.5, 2.05]) or 12-hour PO haemoglobin (10.9 ± 7.3; p = 0.9 [95% CI: –1.03, 0.7, 2.43]) or 24-hour PO haemoglobin (10.7 ± 8.2; p = 0.9 [95% CI: –0.95, 0.9, 2.75]). In addition, there was no significant difference between the pre-operative haemoglobin (11.6 ± 6.4 gms%), and 48-hour PO haemoglobin (11.2 ± 6.9; p = 0.7 [95% CI: –1.28, 0.4, 2.08]), or 1-week PO haemoglobin (11.4 ± 7.5; p = 0.9 [95% CI: –1.55, 0.2, 1.95]).

Conclusions

Routine PO haemoglobin assay after uncomplicated elective CSs is not necessary, especially when the pre-operative haemoglobin before the ECS ≥ 11 gms%, CS duration < 45 min, and estimated intra-operative blood loss ≤ 500 mL.

Gestational Risk as a Determining Factor for Cesarean Section according to the Robson Classification Groups

OBJECTIVE

 To analyze and compare the frequency of cesarean sections and vaginal deliveries through the Robson Classification in pregnant women attended at a tertiary hospital in two different periods.

METHODS

 Cross-sectional, retrospective study of birth records, comprising 4,010 women, conducted from January 2014 to December 2015 in the only public regional referral hospital for the care of high- risk pregnancies, located in Southern Brazil.

RESULTS

 The overall cesarean section rate reached 57.5% and the main indication was the existence of a previous uterine cesarean scar. Based on the Robson Classification, groups 5 (26.3%) and 10 (17.4%) were the most frequent ones. In 2015, there was a significant increase in the frequency of groups 1 and 3 (p < 0.001), when compared with the previous year, resulting in an increase in the number of vaginal deliveries (p < 0.0001) and a reduction in cesarean section rates.

CONCLUSION

 The Robson Classification proved to be a useful tool to identify the profile of parturients and the groups with the highest risk of cesarean sections in different periods in the same service. Thus, it allows monitoring in a dynamic way the indications and delivery routes and developing actions to reduce cesarean rates according to the characteristics of the pregnant women attended.

Cesarean section rates in São Paulo State: regional inequalities in SUS obstetric care

Abstract Objectives: to analyze the relation between cesarean section rates in SUS childbirth care establishments in São Paulo State and urbanization conditions, according to Robson group classification system. Methods: Sistema de Informação sobre Nascidos Vivos (Live Births Information System) and Cadastro Nacional de Estabelecimentos de Saúde (National Registry of Health Establishments) 2016 databases were analyzed. The studied outcome was cesarean section rates in the establishments, grouped by administration type (public or nonprofit entities) and urbanization condition. Results: the cesarean section rate in SUS childbirth care establishments was 50.5%, ranging from 41.1% in metropolitan regions up to 75.2% in the low urbanized regions. Cesarean section rates in public administration establishments (38.2%) were significantly lower than the nonprofit administration maternity hospitals (62.3%). Robson groups 5 and 2 contributed mostly to the cesarean section global rate (36.6% and 21.5%, respectively). Conclusions: The less urbanized regions showed significantly higher cesarean section rates than the metropolitan and highly urbanized regions. Cesarean section rates of public administration establishments were significantly lower than the nonprofit administration establishments. However, when separated by urbanization condition its difference was only observed in the metropolitan regions.

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.

Impact of clinical audits on cesarean section rate in a Spanish hospital: Analysis of 6 year data according to the Robson classification

OBJECTIVES

The aim of this study is to analyze the impact of the introduction of an internal clinical audit on the cesarean section (CS) rate, evaluated according to the Robson Ten Group Classification System (TGCS), and to identify the main contributors to the overall CS rate in order to plan further interventions.

STUDY DESIGN

In 2014, an internal clinic audit committee was established in our center. Modifications of clinical management protocols were also implemented. A retrospective review of clinical records was conducted and pre-audit (2011-2014) results were compared against audit (2015-2018) results. Patients were clustered according to the Robson TGCS and the analyzed outcomes were CS rate and maternal and neonatal results.

RESULTS

Between January 2011 and December 2018, 12,766 women gave birth at our institution among which 2,281 CS were analyzed. After the establishment of the clinical audit, the overall CS rate decreased from 20.27% to 14.82 % (p < 0.01). The major contribution to the overall CS rate in both periods were made by Group 2a (nulliparous with a single cephalic pregnancy at term who underwent labor induction: 4.86 % of all cases), followed by Group 5 (patients with a previous C-section: 3.26 %) and Group 1 (nulliparous with a single cephalic pregnancy at term with spontaneous labor: 2.39 %), representing 59.6 % of all CS. The group that showed the greatest reduction to the overall Cs rate was Group 2 (5.77 % vs 3.96 %, OR 1.48 (p < 0.01). No differences in perinatal and maternal results were found between preaudit and audit group.

CONCLUSION

Audit, feedback, and modification of clinical management protocols may be effective in changing clinical practice and reducing CS rates without worsening maternal and neonatal morbimortality. Robson TGCS allowed us to identify which groups had the greatest impact on CS rate in order to establish new strategies that may lead us to optimize the use of this intervention. It seems that efforts to reduce the overall CS rate should be directed on increasing vaginal birth after CS and reducing CS rates in nulliparous women with single cephalic full-term pregnancy.

Cesarean section rates in Brazil: Trend analysis using the Robson classification system

Cesarean section (CS) is a surgical procedure used to deliver babies that is medically indicated to prevent maternal and neonatal mortality. However, it is associated with short- and long-term risks. CS rates have increased, and efforts are being made to ensure that CS is performed only when necessary. The Robson classification system is considered useful for studying, evaluating, monitoring, and comparing CS rates within and between healthcare facilities. In Brazil, there are few studies on this subject, and no large epidemiological studies on this topic utilizing the Robson classification have been reported. This study aimed to report and analyze CS rates in Brazil using the Robson classification system, and subsequently suggest possible measures to address it.Data were collected from the Brazilian Live Birth Information System (Sistema de Informações sobre Nascidos Vivos) that contains data of the entire obstetric population, from 2014 to 2017. All births in the country during this period were analyzed according to the Robson classification.A total of 11,774,665 live births were reported in Brazil during 2014 to 2017, most of which were mostly via CS (55.8%). Regions with high human development indexes had significantly higher CS rates than those with low human development indexes. The Robson group (RG) 1 to 4 accounts for 60.2% of live births and 47.1% of all CSs. RG5 was larger than all the other groups and contributed to the highest global rate of CS (31.3%), in addition to being the group who presented the largest growth.Although RG 1 to 4 present favorable initial conditions for vaginal delivery, CS accounted for almost half of births in these groups. The size of RG1 and RG2 in Brazil was comparable to that in countries with low CS rates; however, CS rates in these groups were 3 times higher in Brazil. Nulliparous women in RG1 and RG2 who undergo CS are subsequently categorized into RG5, increasing the global CS rate by 1% annually.We suggest the implementation of health policies to avoid the unnecessary performance of CS in RG1 and RG2 to decrease the CS rates in Brazil.

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.

Household- and community-level determinants of low-risk Caesarean deliveries among women in India

Caesarean section delivery rates in India have doubled from 9% in 2005-06 to 17% in 2015-16, increasing the clinical and economic burden on the health care system. This study applied multilevel models to assess the role of household- and community-level factors in Caesarean section (CS) deliveries among low-risk women in India using data from Round 4 of the National Family Health Survey (NFHS-4) conducted in 2015-16. The sample size was 59,318 low-risk women who had their last birth in an institution during the 5 years preceding the survey. These women were nested in 57,279 households, which were nested in 22,183 communities, which were further nested in 640 districts in India. Around 21% of the low-risk women and 24% of all women who had delivered in an institution had undergone CS. The CS rates among low-risk women were extremely high in private institutions (40%) and in southern India (43%). The explanatory variables age, education of women, household wealth and number of antenatal visits were significantly positively associated, while women's parity was negatively associated, with CS delivery among low-risk women. The multilevel analysis suggested that the likelihood of a low-risk woman opting for CS was influenced by a similar decision of another woman from the same household (37%) and/or community (18%). Furthermore, women with low-risk pregnancies from higher educated communities were less likely (OR 0.92) to undergo CS. There is therefore a need for a community-level awareness programme on the risks and benefits of low-risk CS and vaginal delivery, particularly in the southern region of India.

Trend of Cesarean Section Rates and Correlations with Adverse Maternal and Neonatal Outcomes: A Secondary Analysis of Thai Universal Coverage Scheme Data

Objectives  The main purpose of this article is to estimate the trend and projection of cesarean section rates (CSRs) and explore correlations between CSRs with adverse maternal and perinatal outcomes, namely maternal mortality ratios (MMRs), rates of postpartum hemorrhage (PPH), neonatal mortality rates (NMRs), and birth asphyxia per 1,000 live births across all regions of Thailand. Study design  A secondary analysis of the hospital-based database of pregnant women and newborns under the Thai Universal Coverage Scheme between January 2009 and December 2017 was conducted. Results  Overall annual CSR significantly increased from 23.2% in 2009 to 32.5% in 2017. With the same rate of increase, the CSR of 59.1% was projected by the year 2030 that could be reduced to 30.0% if an annual rate of CS reduction of 1% was assumed using Joinpoint regression. The increasing CSRs were significantly correlated with higher MMRs ( r = 0.20, p  = 0.03) and birth asphyxia ( r = 0.39, p  < 0.001). The correlation trends were similar when the analyses were stratified by year in the majority of years. Overall correlations between CSRs and rates of PPH or NMRs were not statistically significant. Conclusion  CSRs in Thailand continuously increased and were correlated with adverse maternal and perinatal outcomes. More effort at the national level to reduce unnecessary CS is urgently required.

Analysing the likelihood of caesarean birth after implementation of the two-childbirth policy in China, using the Ten Group Classification System

The aim of this study was to identify the main contributor to the high Caesarean section birth rate at a regional perinatal medical centre using the Robson Ten Group Classification System (TGCS). A total of 54,085 women were surveyed and were included in our study from 2015 to 2017 at the Women's Hospital at Zhejiang University School of Medicine in Hangzhou, China. The Caesarean birth rate was similar among the three years; although, the new two-childbirth policy in China has been in implementation since 2016. According to the TGCS, Group 5 was the largest contributor to the overall Caesarean birth rate (40.79%), followed by Group 2 (21.36%). The Caesarean birth rate of Group 5 and Group 2 decreased significantly from 2015 to 2017 (p < .05). The proportion of Group 7 contributing to the overall Caesarean birth rate increased significantly (p < .05). Future efforts should focus on increasing vaginal birth after Caesarean in Group 5 and external cephalic version in Group 7 to decrease the overall Caesarean birth rate.Impact statementWhat is already known on this subject? The Ten Group Classification System (TGCS) proposed by World Health Organisation was used in some countries such as Queensland, Singapore and Japan to assess and compare Caesarean section rates. The main contributor to the high Caesarean birth rate varies in different counties. However, it is not widely used in China.What the results of this study add? It was the first study using the TGCS to analyse the Caesarean birth rate and the changes after implementation of the two-childbirth policy in China. It identified that Group 5 (multiparous mothers with a previous Caesarean birth in a singleton, cephalic full-term pregnancy) constituted the most important determinant of overall Caesarean birth rates, followed by Group 2 (nulliparous mothers with a singleton, cephalic full-term pregnancy undergoing an induction of labour or prelabour Caesarean birth). The contribution of Group 5 and Group 7 (multiparous women with a single breech pregnancy) to the overall Caesarean birth rate has increased significantly since the new childbirth policy was implemented.What the implications are of these findings for clinical practice and/or further research? Future efforts should focus on increasing vaginal birth after Caesarean in Group 5 and external cephalic version in Group 7 to decrease the overall Caesarean birth rate in China.

National policies and care provision in pregnancy and childbirth for twins in Eastern and Southern Africa: A mixed-methods multi-country study

BACKGROUND

High-risk pregnancies, such as twin pregnancies, deserve particular attention as mortality is very high in this group. With a view to inform policy and national guidelines development for the Sustainable Development Goals, we reviewed national training materials, guidelines, and policies underpinning the provision of care in relation to twin pregnancies and assessed care provided to twins in 8 Eastern and Southern African countries: Kenya, Malawi, Mozambique, Rwanda, Tanzania, Uganda, Zambia, and Zimbabwe.

METHODS AND FINDINGS

We located policies and guidelines by reviewing national repositories and by contacting experts to systematically map country-level maternal and newborn training materials, guidelines, and policies. We extracted recommendations for care for twins spanning ante-, intra-, and postpartum care that typically should be offered during twin pregnancies and childbirth. We compared care provided for mothers of twins to that provided for mothers of singletons during the ante-, intra-, and postpartum period and computed neonatal mortality rates using the most recent Demographic and Health Surveys (DHS) data for each country. There was a paucity of guidance on care specifically for twin or multiple pregnancies: None of the countries provided clear guidance on additional number of antenatal care visits or specific antenatal content, while 7 of the 8 countries recommended twins to be delivered in a comprehensive emergency obstetric and neonatal care facility. These results were mirrored by DHS results of 73,462 live births (of which 1,360 were twin) indicating that twin pregnancies did not receive more frequent or intensified antenatal care. The percentage of twin deliveries in hospitals varied from 25.3% in Mozambique to 63.0% in Kenya, and women with twin deliveries were between 5 and 27 percentage points more likely to deliver in hospitals compared to women with singleton live births; this difference was significant in 5 of the 8 countries (t test p < 0.05). The percentage of twin deliveries by cesarean section varied from 9% in Mozambique to 36% in Rwanda. The newborn mortality rate among twins, adjusted for maternal age and parity, was 4.6 to 7.2 times higher for twins compared to singletons in all 8 countries.

CONCLUSIONS

Despite the limited sample size and the limited number of clinically relevant services evaluated, our study provided evidence that mothers of twins receive insufficient care and that mortality in twin newborns is very high in Eastern and Southern Africa. Most countries have insufficient guidelines for the care of twins. While our data do not allow us to make a causal link between insufficient guidelines and insufficient care, they call for an assessment and reconceptualisation of policies to reduce the unacceptably high mortality in twins in Eastern and Southern Africa.

Complications associated with higher order compared to lower order cesarean sections

Background: The rate of multiple cesarean sections is persistently on the rise because of cultural demands for large families, and multiple cesarean sections are an important cause of maternal morbidity and mortality.Objectives: This study was designed to detect the complications associated with higher order compared to lower order cesarean sections.Materials and methods: The hospitals record of women who had a cesarean section performed after three or more previous cesarean sections, and those who had a cesarean section for the second time over 2 years reviewed. Women with ≥3 cesarean sections admitted for elective cesarean section after 38 weeks' gestation, and those with ≥3 cesarean sections admitted in labor for emergency cesarean section were included in group 1. Women with history of previous one lower segment cesarean section (LSCS), who refused trial of labor and women with one LSCS who had an emergency cesarean section after failed trial of labor (TOL) were included in group 2. Antenatal, intraoperative, and postoperative data were reviewed. Statistical analysis done using SPSS version 20 (Chicago, Illinois, USA), to detect the complications associated with higher order compared to lower order cesarean sections. Primary outcome measures; complications associated with higher order compared to lower order cesarean sections. Secondary outcome measures; intraoperative, and postoperative complications.Results: Four hundred and fifty (450) women undergoing repeat cesarean section studied; 32.2% (145/450) had ≥3 previous cesarean sections (group 1), and 67.8% (305/450) had previous one cesarean section (group 2). In group 1, 77.2% (112/145) had previous three cesarean sections, 12.4% (18/145) had previous four cesarean sections, 9% (13/145) had previous five cesarean sections, and 1.4% (2/145) had previous six cesarean sections. The proportion of unbooked admission, and emergency cesarean sections were significantly high in group 2 compared to group 1 (11.1% (34/305) and 73.1% (223/305) versus 4.83% (7/145) and 40.7% (59/145); respectively) (p<.05, 95% CI; 0.1-0.2) and p<.01, 95% CI; 0.4-11.4; respectively. The risk of dense omental adhesions, and bladder injuries were significantly high in group 1 compared to group 2 (4.14% (6/145) and 1.38% (2/145) versus 0.66% (2/305) and 0% (0/305); respectively), (p=.01 (95% CI; 0.6-1.6) and p=.01 (95% CI; 0.5-5.5); respectively). Logistic regression analysis showed that the bladder injury was 5 times more (odds ratio 5.0 (95% CI; 0.035-711.8)) and the blood transfusion was 4.7 times more (odds ratio 4.7 (95% CI; 0.147-151.5)) in women with >3 repeat cesarean sections compared to women with previous one cesarean section (insignificant difference p=.52 and .38; respectively).Conclusion: The risk of dense omental adhesions and bladder injury was significantly high in women with previous ≥3 cesarean sections compared to women with previous one cesarean section. Logistic regression analysis showed that the bladder injury was five times more and the blood transfusion was 4.7 times more in women with >3 repeat cesarean sections compared to women with previous one cesarean section (insignificant difference).

Cesarean rates in a Chilean public hospital and the use of a new prioritization criteria: The relevance index

AIM

Cesarean section rates are increasing worldwide and Robson's classification system allows a practical approach to study this phenomenon. C-section in Chile has been indicated as unexpectedly high, with important variability within the country and payment systems. The aim was to report our data using Robson's system and the evolution of local C-section rate in a public hospital during a 9-year period.

METHODS

Retrospective analysis (2005-April 2014), in a metropolitan hospital in Santiago. All deliveries were classified into Robson groups. Time changes were analyzed with Pearson's correlation. P value <0.05 was considered significant. A 'relevance index' (RI) for each group was calculated as 100 × C-S rate × relative contribution.

RESULTS

The overall C-section rate increased from 24 to 27% (P < 0.05) in 53 571 deliveries, with a greater increase in groups 1 (nulliparous, single, term cephalic, spontaneous labor), 3 (multiparous, single, no previous C-S, term cephalic, spontaneous labor) and 4 (multiparous, single, no previous C-S, term cephalic, induced or no labor). Despite no increase in Group 5 (women with one or more previous C-S) this group had the highest RI (20.3), which defined priority for intervention over others.

CONCLUSION

C-S rate was lower than that reported in other centers from Chile and Latin America. Robson's classification and the RI allowed prioritization. Although increase in groups 1, 3 and 4, group 5 needs attention because of stronger impact on overall C-S rate. This analysis allowed to define how to lower C-S rate in our institution.

Trends and predictors of cesarean birth in Singapore, 2005-2014: A population-based cohort study

BACKGROUND

Rates of cesarean birth have continued to rise in many high-income countries. We examined the temporal trends and predictors of cesarean birth in Singapore.

METHODS

Linked hospitalization and Birth Registry data were used to examine all live births to Singaporean citizens and permanent residents between January 1, 2005 and December 31, 2014 (n = 342 932 births). We calculated cesarean rates and age-adjusted average annual percent change (AAPC) in those rates and used sequential multivariable regression modeling to assess the contribution of changes in predictors to the change in cesarean rates over time.

RESULTS

The overall cesarean rate in Singapore rose from 32.2% in 2005 to 37.4% in 2014. Among singleton, cephalic, term pregnancies, the two major predictions of cesarean were nulliparity and previous cesarean, each accounting for just over one-third of all cesareans. Higher AAPC was observed in nulliparous women of Indian ethnicity (0.74% [95% confidence interval 0.68-0.80]) compared with Chinese (0.62% [0.60-0.65]) or Malay women (0.63% [0.59-0.68]), and in women who delivered in private hospitals (0.62% [0.60-0.64]) compared with those delivered under subsidized care in public hospitals (0.58% [0.52-0.63]). Parity and education had the largest influences on cesarean birth trend (attenuation of AAPC from 0.62% [0.59-0.66] to 0.39% [0.38-0.40] after adjustment).

CONCLUSION

Cesarean birth has continued to rise at a steady rate in Singapore. Strategies to curb this temporal increase include avoidance of medically unnecessary primary cesarean and attempts at trial of labor and vaginal delivery among women with a history of prior cesarean.

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

BACKGROUND

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

OBJECTIVE

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

STUDY DESIGN

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

RESULTS

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

CONCLUSION

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

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Role of maternal characteristics and epidural analgesia on caesarean section rate in groups 1 and 3 according to Robson's classification: a cohort study in an Italian university hospital setting

OBJECTIVE

To investigate the role of maternal characteristics and epidural analgesia (EA) on caesarean section (CS) rates in selected groups by using the Robson 10-Group Classification System (RTGCS).

DESIGN

Cohort study.

SETTING

Department of Obstetrics and Gynaecology, Fondazione Policlinico Universitario 'A. Gemelli', Rome, Italy.

PATIENTS

A total of 12 098 deliveries in periods I (1998-1999) and II (2010-2011).

MAIN OUTCOME MEASURES

CS rates in groups 1 and 3 of RTGCS.

RESULTS

In group 1, 1144 (20%) patients were assigned to period I and 1302 (20.4%) to period II, while in group 3, 1587 (27.8%) were assigned to period I and 1502 (23.5%) to period II. CS rates were 16.4% and 23.1% in group 1 and 12.7% and 10.9% in group 3 in periods I and II, respectively. In group 1, significant and independent contributions to CS rate were provided by maternal age (p=0.018; OR 0.95 (95% CI 0.85 to 0.97)), body mass index (BMI) (p=0.022; OR 0.89 (95% CI 0.85 to 0.91)) and EA administration (p=0.037; OR 0.59 (95% CI 0.43 to 0.77)). In group 3, maternal age (p<0.001; OR 0.93 (95% CI 0.89 to 0.96)) and BMI (p=0.023; OR 0.98 (95% CI 0.96 to 0.99)) were found to be significantly associated with CS.

CONCLUSIONS

RTGCS is an effective tool for analysing changes in obstetric care, allowing for the recognition of maternal age, BMI and EA administration in the strategic planning for mitigation of CS rates in selected groups.

Use of the 10-Group Classification System to analyze how the population control policy change in China has affected cesarean delivery

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.