Achievement of appropriate cesarean rates using Robson's 10-Group classification system in Brazilian private practice.

BACKGROUND: Increasing cesarean section (CS) rates are a global concern because they are related to higher maternal and neonatal complication rates and do not provide positive childbirth experiences. In 2019, Brazil ranked second globally, given its overall CS rate of 57%. According to the World Health Organization (WHO), populational CS rates of 10-15% are associated with decreased maternal, neonatal, and infant mortality rates. This study aimed to investigate whether multidisciplinary care following evidence-based protocols associated with a high motivation of both women and professionals for a vaginal birth leads to less overuse of CS in a Brazilian private practice (PP). METHODS: This cross-sectional study evaluated CS rates by Robson group for women who sought vaginal birth in a private practice in Brazil comparing with Swedish data. Collaborative care of midwives and obstetricians who adopted evidence-based guidelines was offered. CS rates, overall and by Robson group, contribution of each Robson group to the overall CS rate, clinical and nonclinical interventions, vaginal birth, pre-labor CS, and intrapartum CS proportions were estimated. The expected CS rate was calculated using the World Health Organization C-model tool. The analysis used Microsoft Excel and R Studio (version 1.2.1335. 2009-2019). RESULTS: The PP overall CS rate was 15.1% (95%CI, 13.4-17.1%) versus the 19.8% (95%CI, 14.8-24.7%) rate expected by the WHO C-model tool. The population included 43.7% women in Robson Group 1 (nulliparous, single, cephalic, at term, spontaneous labor), 11.4% in Group 2 (nulliparous, single, cephalic, at term, induced labor or CS before labor), and 14.9% in Group 5 (multiparous women with previous CS), the greatest contributors to higher CS rates (75.4% of them). The Swedish overall CS rate was 17.9% (95%CI, 17.6-18.1%) in a population of 27% women in Robson Group 1, 10.7% in Group 2, and 9.2% in Group 5. CONCLUSIONS: Multidisciplinary care following evidence-based protocols, associated with high motivation of both women and professionals for vaginal birth, may lead to a significant and safe reduction of CS rates even in contexts such as Brazil, with high medicalization of obstetric care and excess CS.

Alternations of cesarean section rates in a non-infected population after the outbreak of COVID-19: a cross-sectional study.

The pandemic of Coronavirus Disease 2019(COVID-19) could be sources of anxiety among pregnant women and health care workers, which might affect the decision making on the mode of delivery. The aim of this study was to explore whether the cesarean section rates had significantly increased after the outbreak of COVID-19. We analyzed the labor data with cesarean rates in a tertiary maternity center during COVID-19 epidemic months from January to March in 2020, compared with pre-epidemic parallel months in 2019 by using Z-score test for proportions. Even though none of the staff or patient suffered with COVID-19 in the hospital, we found the cesarean section rates slightly increased in a non-infected population after the outbreak of COVID-19. Obstetricians should beware of the possible effects of COVID-19 on the mode of delivery.

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.

Investigation of cesarean sections at Konya Training and Research Hospital Obstetrics and Gynecology Department between 2010 and 2015.

OBJECTIVE: Analysis of the annual distribution of cesarean sections and indications between 2010 and 2015 in our clinic. MATERIAL AND METHODS: Medical records of 10,437 cesarean section patients from a total number of 24,283 deliveries performed at Department of Obstetrics and Gynecology between 2010-2015 were evaluated retrospectively. The indications for Cesarean section were analyzed and compared based on years. RESULTS: The lowest cesarean section rate was 18.67% in 2011 and the highest rate was 24.5% in 2013, and the annual rates were close to each other in this 6-year period (p > 0.05). History of uterine surgery was the indication with the highest rate of 49.52%, while fetal distress was the second most frequent with 12.53%; presentation anomalies were observed as the most frequent third indication with 7.55%, and umbilical cord prolapse was the least frequent indication with 0.33%. CONCLUSIONS: Patient education about normal delivery and providing means for pain control during normal delivery, improvement in physical conditions of the clinics, frequent and regular training of the assisting staff with obstetrics physicians are important to diminish the rates of primary cesarean sections. In addition, a normal delivery after a previous cesarean section must be encouraged.

Rational dissection of a high institutional cesarean section rate: an analysis using the Robson Ten Group Classification System.

AIM: Cesarean section (CS) rates have risen far in excess of the optimal 15% recommended by the World Health Organization. The Robson Ten Group Classification System (TGCS) allows meaningful analysis of a CS rate. The aim of this study is to identify the leading patient categories contributing to our institution's CS rate. METHODS: Prospective study of all women who delivered at the Singapore General Hospital from January 2008 to December 2011. The following data was recorded: parity, singleton/multiple pregnancy, previous CS, mode of labor onset and gestational age at delivery. CS rates were computed for each group, as well as their relative contribution to the overall CS rate. RESULTS: There were 6074 deliveries, in which 2011 (33.1%) women had CS delivery. Group 5 was the largest contributor to the overall CS rate (25.9%). Of the patients in this group, 18.8% had a successful vaginal birth after cesarean (VBAC). Group 2 was the second largest contributor to the overall CS rate at 18.0%. Group 10 had a high contribution of 16.1%. CONCLUSION: The TGCS allows easy identification of the leading contributing patient groups. The surprisingly high contribution of group 10 suggests that our institution, a tertiary multidisciplinary teaching hospital, manages a sizeable group of high-risk patients in its obstetric case mix accounting for the high CS rate. Almost one in five term pregnancies with one previous CS had a successful vaginal delivery, suggesting that the institutional attempted VBAC rate is higher than 20%.

Primary cesarean section rate among full-term pregnant women with non-previous uterine scar in a hospital of Vietnam.

Aim: This article aims to determine the contributing indications for primary cesarean sections among full-term pregnant women with non-previous uterine scars and suggests several potential solutions to reduce the cesarean section rate. Methods: This is a descriptive study with data being retrospectively collected from electronic medical records (EMRs) at Hanoi Obstetrics & Gynecology Hospital, Vietnam, in 2020. We studied 23,631 women at ≥37 weeks of gestation with non-previous uterine scars. Main ICD-10 categories of diagnosis on the EMRs were used to classify the indications. The proportions of indications for primary cesarean sections were calculated, thereby offering potential solutions to reduce the cesarean section rate. Results: The proportion of cesarean sections among full-term pregnancies with non-previous uterine scars was 40.7%. The most common indications for primary cesarean sections were non-reassuring fetal heart rate tracing (40%), labor arrest (31%), and maternal request (11%). Among the low-risk pregnant women, the cesarean section rate was 35.9%, of which the percentages of labor arrest and non-reassuring fetal heart rate tracings and maternal request were 13.6%, 17.7%, and 4.6%, respectively. Conclusions: The proportion of primary cesarean sections among full-term pregnancies with non-previous uterine scars is high; non-reassuring fetal heart rate tracings, labor arrest, and maternal request were three main indications. It is necessary to build the strategies of health organizations regarding the management of clinical practices and the programs improving the knowledge, attitudes, practices of pregnant women and obstetricians regarding cesarean sections.

Examining the role and relevance of the critical analysis and comparison of cesarean section rates in a changing world.

Cesarean section (CS) is one of the most commonly performed surgical operations in the world and has resulted in improved maternal and neonatal morbidity and mortality rates internationally. However, concerns have been raised regarding the ever increasing CS rates to what has been described as 'epidemic' proportions. Global CS rates have increased from 6.7% in 1990 to 19.1% in 2014. However, there is a vast variation in the CS rates between countries with CS rates of 44.3% reported across Latin America & the Caribbean and CS rates as low as 4.1% in central and West Africa. There is much controversy regarding the optimal figure for CS in a population. The optimal CS rates for a population have been recommend in various studies, ranging from 10% to 19%, above which no reported improvement in maternal and neonatal mortality rates is observed. This review examines the evolution of the changing indications for CS and increasing CS rates in a world where family sizes are reducing and maternal age at first pregnancy is increasing. Efforts must be made to agree on an appropriate classification system whereby CS rates can be compared accurately between units and countries as a useful tool to audit and monitor our practice. Obstetricians should consider the indications for each CS performed, be conscious of the CS rate in our own countries and institutions and most importantly, be cognizant of how the CS rate impacts the maternal and perinatal morbidity and mortality rates and adjust our practice accordingly, to minimize harm.

Differences in Cesarean section rates by fetal sex among Chinese women in the United States: Does Chinese culture play a role?

To investigate whether elements of Chinese culture, such as son preference, influence women's mode of child delivery, this paper analyzes how fetal sex affects C-section rates among Chinese mothers compared with Japanese mothers in the United States. It uses birth certificate data from 1990 to 2000, a period when women were routinely able to learn the sex of the fetus during pregnancy. Compared with Japanese mothers, Chinese mothers were 1 percentage point more likely to undergo C-section when giving birth to boys than when giving birth to girls. This result is robust to the addition of a rich set of controls and the restriction of the sample to infants without congenital diseases or anomalies at birth. The effects are concentrated in subgroups that are more likely to prefer sons-specifically, where both parents are Asian or where mothers are first-generation immigrants. The findings offer valuable insights for health professionals into culturally driven pregnancy behaviors among Chinese women, potentially enabling them to offer more culturally appropriate healthcare as they support women in making a healthy transition to motherhood.

Is Primary Cesarean Section a Cause of Increasing Cesarean Section Rates in Greece?

INTRODUCTION: Cesarean Section is a surgical procedure which can be life saving and necessary in some circumstances. Nonetheless, Cesarean Delivery continues to result in increased complications for subsequent deliveries as well as increased financial costs. This phenomenon raises concerns over the growing rates of Cesarean deliveries among women at low risk for a complicated birth whose first delivery was by Cesarean Section for non-medical reasons. AIM: The aim of this study was to determine whether PCS is a main factor in the overall percentage of CS in Greece and define the causes of elective and emergency cesarean sections in primary ones. METHODS: From 365 cesarean deliveries during the research period, a sample of 162 women who underwent a primary cesarean section at a Greek University hospital has consented to participate. Medical and demographic data as well as data from women's medical dossier were used in the day 3 postpartum. RESULTS: Out of 162 primiparous mothers, 38.9% underwent an emergency cesarean section and 61.1% an elective cesarean section. Furthermore, the results show that women, who had been diagnosed with stress disorders or depression, with abnormal fetal heart rate, pathological NST/Doppler and had developed complications after cesarean section, were more likely to undergo an emergency cesarean delivery. CONCLUSION: This survey shows the lack of evidence-based guidelines in obstetrician's practice and the lack of perinatal support centers in Greece. Primary CS can be characterized as a key factor in the overall increase of CS, given the vicious cycle of recurrence of a Cesarean delivery.

Validation of a statistical toolkit based on the ten-group Robson Classification of cesarean delivery.

OBJECTIVE: To assess the validity of a statistical toolkit based on the original ten-group Robson Classification of cesarean delivery. METHODS: A retrospective pilot study at Al Wakra Hospital in Doha, Qatar, was conducted from June 1 to June 30, 2017, involving consecutive women undergoing cesarean delivery, using a three-stage approach. A Microsoft Excel-based toolkit was developed by dividing each of the 10 groups of the original Robson Classification into clinical groups and subgroups. A critical review of the toolkit was then undertaken by four independent physicians based on different potential clinical scenarios that could culminate in cesarean delivery in each Robson group. The toolkit was validated by populating it with the data of the cesarean deliveries of the women involved in the study. RESULTS: The data from cesarean deliveries of 153 women were utilized in the pilot study. The toolkit catered for and successfully accommodated 94.8% of the cases without any need for change. The remaining 5.2% of cases required additional adjustments in the toolkit. The toolkit provided instant access to important data about the labor and delivery which could be used for audit and research purposes and ultimately for service improvement. CONCLUSION: The toolkit significantly improved the clinical efficacy of the Robson Classification as a potential statistical tool for comparison of local and international data.

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.

Increased Cesarean Section Rates during the COVID-19 Pandemic: Looking for Reasons through the Robson Ten Group Classification System / Aumento das taxas de cesárea durante a pandemia de COVID-19: procurando explicações por meio da Classificação de Robson

Abstract Objective To compare cesarean section (CS) rates according to the Robson Ten Group Classification System (RTGCS) and its indications in pregnant women admitted for childbirth during the first wave of the coronavirus disease 2019 (COVID-19) pandemic with those of the previous year. Materials and Methods We conducted a cross-sectional study to compare women admitted for childbirth from April to October 2019 (before the pandemic) and from March to September 2020 (during the pandemic). The CSs and their indications were classified on admission according to the RTGCS, and we also collected data on the route of delivery (vaginal or CS). Both periods were compared using the Chi-squared (χ2) test or the Fisher exact test. Results In total, 2,493 women were included, 1,291 in the prepandemic and 1,202 in the pandemic period. There was a a significant increase in the CS rate (from 39.66% to 44.01%; p = 0.028), mostly due to maternal request (from 9.58% to 25.38%; p < 0.01). Overall, groups 5 and 2 contributed the most to the CS rates. The rates decreased among group 1 and increased among group 2 during the pandemic, with no changes in group 10. Conclusion There was an apparent change in the RTGSC comparing both periods, with a significant increase in CS rates, mainly by maternal request, most likely because of changes during the pandemic and uncertainties and fear concerning COVID-19.

Resumo Objetivo Comparar as taxas de cesárea segundo a Classificação de Robson, assim como suas indicações, em mulheres admitidas para parto durante a primeira onda de doença do coronavírus 2019 (coronavirus disease 2019, COVID-19, em inglês), com as do ano anterior. Materiais e Métodos Conduzimos um estudo transversal que comparou as mulheres admitidas para parto entre abril e outubro de 2019 (pré-pandemia) e entre março e setembro de 2020 (durante a pandemia). As cesarianas e as suas indicações foram classificadas conforme o sistema proposto por Robson, e obteve-se a via de parto (vaginal ou cesárea). Ambos os períodos foram comparados usando-se os testes do Qui quadrado ou o exato de Fisher. Resultados Ao todo, 2.943 mulheres foram incluídas, das quais 1.291 antes da pandemia e 1.202 durante a pandemia. A taxa de cesárea aumentou significativamente (de 39.66% para 44,01%; p = 0,028), principalmente devido a desejo materno (de 9,58% para 25,38%; p < 0,01). Os grupos 5 e 2 foram os que mais contribuíram para as taxas de cesárea. Durante a pandemia, o grupo 1 reduziu sua frequência, enquanto o grupo 2 a aumentou. Conclusão Houve uma aparente mudança nas características da população conforme a classificação de Robson. Observou-se significativo aumento nas taxas de cesárea, principalmente por desejo materno, o que reflete possíveis incertezas e medos relacionados à COVID-19.

Is elective induction safe? A prospective analysis.

OBJECTIVES: To identify whether electively induced labor places the mother or her fetus at an increased risk as compared to her spontaneous labor cohort. To quantify the risk of cesarean section in the induced group. METHODS: A prospective analysis comparing 200 electively induced parturients with 200 matched controls who labored spontaneously, in 1 year from April 2007 to April 2008. The parturients were between 37 and 41 weeks of gestation and had no complications necessitating induction. RESULTS: Induction per se was not associated with a statistically significant increase in cesarean section rates. Only when associated with nulliparity, low bishop score, and birth weight >3.5 kg, the risk of cesarean increases. CONCLUSION: Elective induction does not appear to pose an increased risk to the mother or her fetus in a carefully selected patient population. However, when associated with risk factors the cesarean rate increases. Hence informed consent should be taken before induction.

Effect of Repeated Public Releases on Cesarean Section Rates / 예방의학회지

OBJECTIVES: Public release of and feedback (here after public release) on institutional (clinics and hospitals) cesarean section rates has had the effect of reducing cesarean section rates. However, compared to the isolated intervention, there was scant evidence of the effect of repeated public releases (RPR) on cesarean section rates. The objectives of this study were to evaluate the effect of RPR for reducing cesarean section rates. METHODS: From January 2003 to July 2007, the nationwide monthly institutional cesarean section rates data (1 951 303 deliveries at 1194 institutions) were analyzed. We used autoregressive integrated moving average (ARIMA) time-series intervention models to assess the effect of the RPR on cesarean section rates and ordinal logistic regression model to determine the characteristics of the change in cesarean section rates. RESULTS: Among four RPR, we found that only the first one (August 29, 2005) decreased the cesarean section rate (by 0.81 percent) and continued to have an impact period through the last observation in May 2007. Baseline cesarean section rates (OR, 4.7; 95% CI, 3.1 to 7.1) and annual number of deliveries (OR, 2.8; 95% CI, 1.6 to 4.7) of institutions in the upper third of each category at before first intervention had a significant contribution to the decrease of cesarean section rates. CONCLUSIONS: We could not found the evidence that RPR has had the significant effect of reducing cesarean section rates. Institutions with upper baseline cesarean section rates and annual number of deliveries were more responsive to RPR.