Cesarean section rates, Cross-sectional study, Optimizing CS rates in South Asia, Robson Ten Group Classification System
Citation Information :
Hassan L, Woodbury L, Jamal N, Baral G, Ferdous J, Sohail R, Babak S, Chowdhury S, Wasim T, Ratnasiri UD, ur Rehman A. Examining the Efficacy of the Robson Classification System for Optimizing Cesarean Section Rates in South Asia. J South Asian Feder Obs Gynae 2020; 12 (6):366-371.
Aim: To apply the Robson Ten Group Classification System (TGCS) in major South Asian hospitals to begin making recommendations to optimize cesarean section (CS) rates. Materials and methods: This cross-sectional study was conducted from September 2018 to February 2019 at public sector hospitals in five South Asian countries. We analyzed the pooled data for all five hospitals. The data were then stratified by the study hospitals. We utilized a Pearson χ2 test to assess differences in CS by group. And p values <0.05 were considered statistically significant. Statistical analysis was performed using STATA 16. Results: A total of 37,251 women delivered in the five participating hospitals during the 6-month study period. Of these, 13,592 women were delivered by CS with a composite CS rate of 36% (range, 22–53%). Women in groups 1, 2, and 5 were the largest contributors to the overall CS rate in the participating hospitals. Statistically significant differences in CS rates between the hospitals were found in all groups except group 9. Conclusion: TGCS is useful as a starting point with which to identify patient groups warranting interventions to optimize CS. However, data collection alone is not sufficient. Analysis and interpretation should also include assessing maternal and neonatal outcomes. Clinical significance: Preliminary findings indicate that strategies to optimize the use of CS should include avoidance of medically unnecessary primary CS and increasing vaginal birth after cesarean.
Betrán AP, Ye J, Moller AB, et al. The increasing trend in caesarean section rates: global, regional and national estimates: 1990–2014. PLoS One 2016;11(2):e0148343. DOI: 10.1371/journal.pone.0148343.
Najneen S, Tasnim S, Mishu S, et al. Barriers to ethical decision-making on cesarean section in South Asia: a systematic review. 2019. Available at: https://www.researchgate.net/publication/331876821 [Retrieved August 14, 2019].
National Institute of Population Studies Pakistan. Pakistan demographic health survey 2017–2018. Available at: https://dhsprogram.com/pubs/pdf/FR354/FR354.pdf [Retrieved July 20, 2019].
Rosmans C, Holtz S, Stanton C. Socioeconomic differentials in caesarean rates in developing countries: a retrospective analysis. Lancet 2006;368(9546):1516–1523. DOI: 10.1016/S0140-6736(06)69639-6.
Cavallaro FL, Cresswell JA, França GV, et al. Trends in caesarean delivery by country and wealth quintile: cross-sectional surveys in southern Asia and sub-Saharan Africa. Bull World Health Organ 2013;91(12):914–922. DOI: 10.2471/BLT.13.117598.
Boatin AA, Schlotheuber A, Betran AP, et al. Within country inequalities in caesarean section rates: observational study of 72 low and middle income countries. BMJ 2018;360:55. DOI: 10.1136/bmj.k55.
Boerma T, Ronsmans C, Melesse DY, et al. Optimising caesarean section use global epidemiology of use of and disparities in caesarean sections. Lancet 2018;392(10155):1341–1348. DOI: 10.1016/S0140-6736(18)31928-7.
Ye J, Zhang J, Mikolajczyk R, et al. Association between rates of caesarean section and maternal and neonatal mortality in the 21st century: a worldwide population-based ecological study with longitudinal data. BJOG 2016;123(5):745–753. DOI: 10.1111/1471-0528.13592.
Lumbiganon P, Laopaiboon M, Gülmezoglu AM, et al. Method of delivery and pregnancy outcomes in Asia: the WHO global survey on maternal and perinatal health 2007–08. Lancet 2010;375(9713):490–499. DOI: 10.1016/S0140-6736(09)61870-5.
Sandall J, Tribe RM, Avery L, et al. Optimising caesarean section use short-term and long-term effects of caesarean section on the health of women and children. Lancet 2018;392(10155):1349–1357. DOI: 10.1016/S0140-6736(18)31930-5.
Betrán AP, Temmerman M, Kingdon C, et al. Optimising caesarean section use interventions to reduce unnecessary caesarean sections in healthy women and babies. Lancet 2018;392(10155):1358–1368. DOI: 10.1016/S0140-6736(18)31927-5.
WHO Human Reproduction Programme. WHO statement on caesarean section rates. Reprod Health Matters 2015;23(45):149–150. DOI: 10.1016/j.rhm.2015.07.007.
Vissar GHA, Ayres-de-Campos D, Barnea ER, et al. FIGO position paper: how to stop the caesarean section epidemic. Lancet 2018;392(10155):1286–87. DOI: 10.1016/S0140-6736(18)32113-5.
Betrán AP, Vindevoghel N, Souza JP, et al. A systematic review of the Robson classification for caesarean section: what works, doesn't work and how to improve it. PLoS One 2014;9(6):e97769. DOI: 10.1371/journal.pone.0097769.
Kazmi T, Saiseema S, Khan S. Analysis of cesarean section rate—according to Robson's 10-group classification. Oman Med J 2012;27(5):415–417. DOI: 10.5001/omj.2012.102.
Varija T, Veerendra KCM, Chandrasekhar T. Analysis of caesarean section rate in tertiary care hospital according to Robson's 10 groups classification. Int J Reprod Contracept Obstet Gynecol 2018;7(4):1380–1384. DOI: 10.18203/2320-1770.ijrcog20181023.
Tanaka K, Mahomed K. The ten group Robson classification: a single center approach identifying strategies to optimize caesarean section rates. Obstet Gynecol Int 2017;2017:5648938. DOI: 10.1155/2017/5648938.
Tura AK, Pijpers O, de Man M, et al. Analysis of caesarean sections using Robson 10-group classification system in a university hospital in eastern Ethiopia: a cross-sectional study. BMJ 2018;8(4):e020520. DOI: 10.1136/bmjopen-2017-020520.
Senanayake H, Piccoli M, Valente EP, et al. Implementation of the WHO manual for Robson classification: an example from Sri Lanka using a local database for developing quality improvement recommendations. BMJ Open 2019;9(2):e027317. DOI: 10.1136/bmjopen-2018-027317.
WHO. Robson classification: implementation manual. World Health Organization; 2017. Available at: https://apps.who.int/iris/bitstream/handle/10665/259512/9789241513197-eng.pdf;jsessionid=FA511B443D15805A49E23F5925BC2A01?sequence=1 [Retrieved December 12, 2018].
Robson M, Murphy M, Byrne F. Quality assurance: the 10-group classification system (Robson classification), induction of labor, and cesarean delivery. Int J Gynaecol Obstet 2015;131(Suppl. 1):S23–S27. DOI: 10.1016/j.ijgo.2015.04.026.
World Bank. Afghanistan—reproductive health at a glance. Washington, DC: World Bank; 2011. Available at: http://documents.worldbank.org/curated/en/262581467996765917/Afghanistan-Reproductive-health-at-a-glance [Retrieved July 10, 2016]; World Bank. Pakistan—reproductive health at a glance. Washington, DC: World Bank; 2011. Available at: http://documents.worldbank.org/curated/en/512941468325459864/Pakistan-Reproductive-health-at-a-glance [Retrieved July 10, 2016]; World Bank. India—reproductive health at a glance. Washington, DC: World Bank; 2011. Available at: http://documents.worldbank.org/curated/en/743521468050934458/India-Reproductive-health-at-a-glance [Retrieved July 10. 2016]; World Bank. Nepal—reproductive health at a glance. Washington, DC: World Bank; 2011. Available at: http://documents.worldbank.org/curated/en/357801468289200282/Nepal-Reproductive-health-at-a-glance [Retrieved July 10, 2016].
Brennan DJ, Robson MS, Murphy M, et al. Comparative analysis of international cesarean delivery rates using 10-group classification identifies significant variation in spontaneous labor. Am J Obstet Gynecol 2009;201(3):308. DOI: 10.1016/j.ajog.2009.06.021.
Robson M. A global reference for CS at health facilities? Yes, but there is work to do. BJOG 2016;123(3):437. DOI: 10.1111/1471-0528.13619.
Brennan DJ, Murphy M, Robson MS, et al. The singleton, cephalic, nulliparous woman after 36 weeks of gestation: contribution to overall cesarean delivery rates. Obstet Gynecol 2011;117(2 pt 1):273–279. DOI: 10.1097/AOG.0b013e318204521a.
Litorp H, Kidanto HL, Nystrom L, et al. Increasing caesarean section rates among low-risk groups: a panel study classifying deliveries according to Robson at a university hospital in Tanzania. BMC Pregnancy Childbirth 2013;13:107. DOI: 10.1186/1471-2393-13-107.
Lundgren I, Healy P, Carroll M, et al. Clinicians’ views of factors of importance for improving the rate of VBAC (vaginal birth after caesarean section): a study from countries with low VBAC rates. BMC Pregnancy and Childbirth 2016;16(1):350. DOI:10.1186/s12884-016-1144-0.
Montagu D, Sudhinaraset M, Diamond-Smith N, et al. Where women go to deliver: understanding the changing landscape of childbirth in Africa and Asia. Health Policy Plan 2017;32(8):1146–1152. DOI: 10.1093/heapol/czx060.
Neuman M, Alcock G, Azad K, et al. Prevalence and determinants of caesarean section in private and public health facilities in underserved South Asian communities: cross-sectional analysis of data from Bangladesh, India and Nepal. BMJ 2014;4(12):e005982. DOI: 10.1136/bmjopen-2014-005982.
Sobhy S, Arroyo-Manzano D, Murugesu N, et al. Maternal and perinatal mortality and complications associated with caesarean section in low-income and middle income countries: a systematic review and meta-analysis. Lancet 2019;393(10184):1973–1982. DOI: 10.1016/S0140-6736(18)32386-9.
Mian NU, Alvi MA, Malik MZ, et al. Approaches towards improving the quality of maternal and newborn health services in South Asia: challenges and opportunities for healthcare systems. Global Health 2018;14(1):17. DOI: 10.1186/s12992-018-0338-9.
Akseer N, Kamali M, Arifeen SE, et al. Progress in maternal and child health: how has South Asia fared? BMJ 2017;357:1–6. DOI: 10.1136/bmj.j1608.
Sobhy S, Zamora J, Dharmarajah K, et al. Anaesthesia-related maternal mortality in low-income and middle-income countries: a systematic review and meta-analysis. Lancet Glob Health 2016;4:e320–e327. DOI: 10.1016/S2214-109X(16)30003-1.
Souza JP, Gülmezoglu A, Lumbiganon P, et al. Caesarean section without medical indications is associated with an increased risk of adverse short-term maternal outcomes: the 2004–2008 WHO Global Survey on Maternal and Perinatal Health. BMC Med 2010;8:71. DOI: 10.1186/1741-7015-8-71.
Keag OE, Norman JE, Stock SJ. Long-term risks and benefits associated with cesarean delivery for mother, baby, and subsequent pregnancies: systematic review and meta-analysis. PLoS Med 2018;15(1):e1002494. DOI: 10.1371/journal.pmed.1002494.
Marshall NE, Fu R, Guise JM. Impact of multiple cesarean deliveries on maternal morbidity: a systematic review. Am J Obstet Gynecol 2011;205(3):262.e1–262.e8. DOI: 10.1016/j.ajog.2011.06.035.
Jauniaux E, Bhide A, Kennedy A, et al. FIGO consensus guidelines on placenta accreta spectrum disorders: prenatal diagnosis and screening. Int J Gynecol Obstet 2018;140(3):274–280. DOI: 10.1002/ijgo.12408.
Chigbu CO, Ezeome IV, Iloabachie GZ. Cesarean section on request in a developing country. Int J Gynecol Obstet 2007;96(1):54–56. DOI: 10.1016/j.ijgo.2006.09.032.
Robson M, Hartigan L, Murphy M. Methods of achieving and maintaining an appropriate caesarean section rate. Best Pract Res Clin Obstet Gynaecol 2013;27:297–308. DOI: 10.1016/j.bpobgyn.2012.09.004.
Lundgren I, Limbeek E, Vehvilainen-Julkunen K, et al. Clinicians’ views of factors of importance for improving the rate of VBAC (vaginal birth after caesarean section): a qualitative study from countries with high VBAC rates. BMC Pregnancy Childbirth 2015;15:196. DOI: 10.1186/s12884-015-0629-6.