Is the Robson's classification system burdened by obstetric pathologies, maternal characteristics and assistential levels in comparing hospitals cesarean rates? A regional analysis of class 1 and 3

Crude and adjusted comparisons of cesarean delivery rates using the Robson classification: A population-based cohort study in Canada and Sweden, 2004 to 2016

BACKGROUND

The Robson classification has become a global standard for comparing and monitoring cesarean delivery (CD) rates across populations and over time; however, this classification does not account for differences in important maternal, fetal, and obstetric practice factors known to impact CD rates. The objectives of our study were to identify subgroups of women contributing to differences in the CD rate in Sweden and British Columbia (BC), Canada using the Robson classification and to estimate the contribution of maternal, fetal/infant, and obstetric practice factors to differences in CD rates between countries and over time.

METHODS AND FINDINGS

We conducted a population-based cohort study of deliveries in Sweden (January 1, 2004 to December 31, 2016; n = 1,392,779) and BC (March 1, 2004 to April 31, 2017; n = 559,205). Deliveries were stratified into Robson categories and the CD rate, relative size of each group and its contribution to the overall CD rate were compared between the Swedish and the Canadian cohorts. Poisson and log-binomial regression were used to assess the contribution of maternal, fetal, and obstetric practice factors to spatiotemporal differences in Robson group-specific CD rates between Sweden and BC. Nulliparous women comprised 44.8% of the study population, while women of advanced maternal age (≥35 years) and women with overweight/obesity (≥25 kg/m2) constituted 23.5% and 32.4% of the study population, respectively. The CD rate in Sweden was stable at approximately 17.0% from 2004 to 2016 (p for trend = 0.10), while the CD rate increased in BC from 29.4% to 33.9% (p for trend < 0.001). Differences in CD rates between Sweden and BC varied by Robson group, for example, in Group 1 (nullipara with a term, single, cephalic fetus with spontaneous labor), the CD rate was 8.1% in Sweden and 20.4% in BC (rate ratio [RR] for BC versus Sweden = 2.52, 95% confidence interval [CI] 2.49 to 2.56, p < 0.001) and in Group 2 (nullipara, single, cephalic fetus, term gestation with induction of labor or prelabor CD), the rate of CD was 37.3% in Sweden and 45.9% in BC (RR = 1.23, 95% CI 1.22 to 1.25, p < 0.001). The effect of adjustment for maternal characteristics (e.g., age, body mass index), maternal comorbidity (e.g., preeclampsia), fetal characteristics (e.g., head position), and obstetric practice factors (e.g., epidural) ranged from no effect (e.g., among breech deliveries; Groups 6 and 7) to explaining up to 5.2% of the absolute difference in the CD rate (Group 2: adjusted CD rate in BC 40.7%, adjusted RR = 1.09, 95% CI 1.08 to 1.12, p < 0.001). Adjustment also explained a substantial fraction of the temporal change in CD rates among some Robson groups in BC. Limitations of the study include a lack of information on intrapartum details, such as labor duration as well as maternal and perinatal outcomes associated with the observed differences in CD rates.

CONCLUSIONS

In this study, we found that several factors not included in the Robson classification explain a significant proportion of the spatiotemporal difference in CD rates in some Robson groups. These findings suggest that incorporating these factors into explanatory models using the Robson classification may be useful for ensuring that public health initiatives regarding CD rates are evidence informed.

Comparison of Cesarean Deliveries in a Multicenter U.S. Cohort Using the 10-Group Classification System

OBJECTIVE

 We sought to (1) use the Robson 10-Group Classification System (TGCS), which classifies deliveries into 10 mutually exclusive groups, to characterize the groups that are primary contributors to cesarean delivery frequencies, (2) describe inter-hospital variations in cesarean delivery frequencies, and (3) evaluate the contribution of patient characteristics by TGCS group to hospital variation in cesarean delivery frequencies.

STUDY DESIGN

 This was a secondary analysis of an observational cohort of 115,502 deliveries from 25 hospitals between 2008 and 2011. The TGCS was applied to the cohort and each hospital. We identified and compared the TGCS groups with the greatest relative contributions to cohort and hospital cesarean delivery frequencies. We assessed variation in hospital cesarean deliveries attributable to patient characteristics within TGCS groups using hierarchical logistic regression.

RESULTS

 A total of 115,211 patients were classifiable in the TGCS (99.7%). The cohort cesarean delivery frequency was 31.4% (hospital range: 19.1-39.3%). Term singletons in vertex presentation with a prior cesarean delivery (group 5) were the greatest relative contributor to cohort (34.8%) and hospital cesarean delivery frequencies (median: 33.6%; range: 23.8-45.5%). Nulliparous term singletons in vertex (NTSV) presentation (groups 1 [spontaneous labor] and 2 [induced or absent labor]: 28.9%), term singletons in vertex presentation with a prior cesarean delivery (group 5: 34.8%), and preterm singletons in vertex presentation (group 10: 9.8%) contributed to 73.2% of the relative cesarean delivery frequency for the cohort and were correlated with hospital cesarean delivery frequencies (Spearman's rho = 0.96). Differences in patient characteristics accounted for 34.1% of hospital-level cesarean delivery variation in group 2.

CONCLUSION

 The TGCS highlights the contribution of NTSV presentation to cesarean delivery frequencies and the impact of patient characteristics on hospital-level variation in cesarean deliveries among nulliparous patients with induced or absent labor.

KEY POINTS

· We report on the cesarean delivery frequencies in a multicenter U.S.

COHORT

. · NTSV gestations (groups 1 and 2) are a primary driver of cesarean deliveries.. · Patient characteristics contributed most to hospital variation in cesarean deliveries in group 2..

Gestational Diabetes Mellitus in Europe: A Systematic Review and Meta-Analysis of Prevalence Studies

Background

Gestational Diabetes Mellitus (GDM) is defined as the type of hyperglycemia diagnosed for the first-time during pregnancy, presenting with intermediate glucose levels between normal levels for pregnancy and glucose levels diagnostic of diabetes in the non-pregnant state. We aimed to systematically review and meta-analyze studies of prevalence of GDM in European countries at regional and sub-regional levels, according to age, trimester, body weight, and GDM diagnostic criteria.

Methods

Systematic search was conducted in five databases to retrieve studies from 2014 to 2019 reporting the prevalence of GDM in Europe. Two authors have independently screened titles and abstracts and full text according to eligibility using Covidence software. A random-effects model was used to quantify weighted GDM prevalence estimates. The National Heart, Lung, and Blood Institute criteria was used to assess the risk of bias.

Results

From the searched databases, 133 research reports were deemed eligible and included in the meta-analysis. The research reports yielded 254 GDM-prevalence studies that tested 15,572,847 pregnant women between 2014 and 2019. The 133 research reports were from 24 countries in Northern Europe (44.4%), Southern Europe (27.1%), Western Europe (24.1%), and Eastern Europe (4.5%). The overall weighted GDM prevalence in the 24 European countries was estimated at 10.9% (95% CI: 10.0-11.8, I2 : 100%). The weighted GDM prevalence was highest in the Eastern Europe (31.5%, 95% CI: 19.8-44.6, I2 : 98.9%), followed by in Southern Europe (12.3%, 95% CI: 10.9-13.9, I2 : 99.6%), Western Europe (10.7%, 95% CI: 9.5-12.0, I2 : 99.9%), and Northern Europe (8.9%, 95% CI: 7.9-10.0, I2 : 100). GDM prevalence was 2.14-fold increased in pregnant women with maternal age ≥30 years (versus 15-29 years old), 1.47-fold if the diagnosis was made in the third trimester (versus second trimester), and 6.79- fold in obese and 2.29-fold in overweight women (versus normal weight).

Conclusions

In Europe, GDM is significant in pregnant women, around 11%, with the highest prevalence in pregnant women of Eastern European countries (31.5%). Findings have implications to guide vigilant public health awareness campaigns about the risk factors associated with developing GDM.

Systematic Review Registration

PROSPERO [https://www.crd.york.ac.uk/PROSPERO/], identifier CRD42020161857.

Caesarean section rates in primigravid women categorised by age and BMI

The rising caesarean section (CS) rate is a complex issue, particularly in an increasingly heterogenous nulliparous population. The study aim was to stratify the CS rate in nulliparous women by age and BMI to determine if any difference existed. This was a retrospective review of CS procedures of nulliparous women in two centres in Ireland (2014 through 2017). Data were obtained for 17,177 women from the hospital databases and CS procedures determined for each age and BMI category. Significant differences were observed when CS rates were stratified in this manner. The CS rates for women <20 years/BMI < 18.5 was 8.8 versus 57.6% for women 35 - 39 years/BMI 30 - 34 and 76 - 100% for all women >45 years (p<.005). The development of customised charts subdivided by age and BMI may be a useful counselling tool and assist in the comparison of rates between units.Impact statementWhat is already known on this subject? It is well known that along with rising CS rates globally, there have also been significant changes in maternal demographics-with increasing maternal age at first birth and increasing maternal BMI. It is well established that both of these factors affect the rate of CS in a population.What do the results of this study add? This study sought to stratify the CS rate in nulliparous women by age and BMI to determine if any difference existed. The results of the study showed an increasing CS rate for increasing age and BMI categories that was statistically significant.What are the implications of these findings for clinical practice and/or further research? Additional research using larger population data sets could allow the development of customised charts for nulliparous women subdivided by age and BMI which could act as a useful counselling tool in clinical practice, as well as assist in the comparison of CS rates between units.

Risk Factors for Intrapartum Cesarean Section Delivery in Low-risk Multiparous Women Following at Least a Prior Vaginal Birth (Robson Classification 3 and 4)

OBJECTIVE

 The aim of the present study was to evaluate the risk factors for cesarean section (C-section) in low-risk multiparous women with a history of vaginal birth.

METHODS

 The present retrospective study included low-risk multiparous women with a history of vaginal birth who gave birth at between 37 and 42 gestational weeks. The subjects were divided into 2 groups according to the mode of delivery, as C-section Group and vaginal delivery Group. Risk factors for C-section such as demographic characteristics, ultrasonographic measurements, smoking, weight gain during pregnancy (WGDP), interval time between prior birth, history of macrosomic birth, and cervical dilatation at the admission to the hospital were obtained from the charts of the patients. Obstetric and neonatal outcomes were compared between groups.

RESULTS

 The most common C-section indications were fetal distress and macrosomia (33.9% [n = 77 and 20.7% [n = 47] respectively). A bivariate correlation analysis demonstrated that mothers aged > 30 years old (odds ratio [OR]: 2.09; 95% confidence interval [CI]: 1.30-3.34; p = 0.002), parity >1 (OR: 1.81; 95%CI: 1.18-2.71; p = 0.006), fetal abdominal circumference (FAC) measurement > 360 mm (OR: 34.20; 95%CI: 8.04-145.56; p < 0.001)) and < 345 mm (OR: 3.06; 95%CI: 1.88-5; p < 0.001), presence of large for gestational age (LGA) fetus (OR: 5.09; 95%CI: 1.35-19.21; p = 0.016), premature rupture of membranes (PROM) (OR: 1.52; 95%CI: 1-2.33; p = 0.041), and cervical dilatation < 5cm at admission (OR: 2.12; 95%CI: 1.34-3.34; p = 0.001) were associated with the group requiring a C-section.

CONCLUSION

 This is the first study evaluating the risk factors for C-section in low-risk multiparous women with a history of vaginal birth according to the Robson classification 3 and 4. Fetal distress and suspected fetal macrosomia constituted most of the C-section indications.

Evaluation of cesarean delivery rates in different levels of hospitals in Jiangsu Province, China, using the 10-Group classification system

OBJECTIVE

To compare cesarean delivery (CD) rates in referral and non-referral hospitals in Maternal Safety Collaboration in Jiangsu province, China.

METHODS

Sixteen participants (4 referral hospitals, 12 non-referral hospitals) from Drum Tower Hospital Collaboration for Maternal Safety reported CD rates in 2019 using ten-group classification system and maternal/neonatal morbidity and mortality.

RESULTS

A total of 22,676 CDs were performed among 52,499 deliveries and the average CD rate was 43.2% (range 34.8-69.6%). CD rate in non-referral hospitals (44.7%) was significantly higher than it was in referral hospitals (40.4%, p < .001). Term singleton cephalic nulliparous women with spontaneous labor (Group 1) or induced labor (Group 2a) had higher CD rates if they were cared in non-referral hospitals compared with those in referral hospitals (Group 1: 11.8% vs. 4.4%, p < .001; Group 2a: 29.1% vs. 21.3%, p < .001). In non-referral hospitals, CD rate in Group 5 and the proportion of Group 5 to the overall population were also significantly higher than those in referral hospitals (98.5% vs. 92.5%, p < .001; and 21.0% vs. 14.5%, p < .001).

CONCLUSION

To decrease the CD rate, we need to take efforts in decreasing unnecessary operations for term singleton cephalic nulliparous women and increasing the rate of trial of labor after CD.

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.

Pregnancy in Charcot-Marie-Tooth disease: Data from the Italian CMT national registry

OBJECTIVE

To collect information on frequency of pregnancy and delivery complications in Charcot-Marie-Tooth (CMT) disease and on CMT course during pregnancy.

METHODS

Through an ad hoc online questionnaire, we investigated pregnancy and neuropathy course in women with CMT adhering to the Italian CMT Registry. Data were compared to those of controls (recruited among friends and unaffected relatives) and the Italian (or other reference) population.

RESULTS

We collected data on 193 pregnancies from 86 women with CMT (age 20-73 years) with 157 deliveries (81.4%) after a mean of 38.6 gestational weeks. In women with CMT, there were no differences compared to controls (59 pregnancies and 46 deliveries from 24 controls) and the reference population for miscarriages (11.4%) and planned (21.0%) and emergency (14.0%) cesarean sections. We found a significantly higher frequency of placenta previa (1.6% vs 0.4%), abnormal fetal presentations (8.4% vs 4.5%), and preterm deliveries (20.3% vs 6.9%; most in week 34-36 of gestation) compared to reference populations. Excluding twins, newborn weight did not differ from the reference population. Postpartum bleeding rate in patients with CMT (2.1%) was similar to that of the general population (2.4%). CMT status worsened during 18 of 193 pregnancies (9.3%) with no recovery in 16 of them and with similar figures in the CMT1A and non-CMT1A subtypes.

CONCLUSIONS

We observed higher rates of placenta previa, abnormal presentations, and preterm deliveries in CMT, but pregnancy outcome and newborn weight and health were similar to those of the reference populations. Worsening of CMT is not infrequent and occurs not only in CMT1A. Pregnant women with CMT should be monitored with particular care.

Patient anxiety of verticalization on day 0 after a Cesarean section

Purpose

The ERAS protocol recommends fast mobilization of a patient along with providing psychological comfort; however, early verticalization can generate mental discomfort. In the post-operative period after Caesarean section (CC), a patient may experience pain, anxiety and negative affect. The main aim of the study was to investigate levels of patient anxiety concerning verticalization on day 0 after CC using. Also, the dependence between anxiety of verticalization and the following: pain, anxiety as a permanent disposition, resistance to pain, negative and positive emotions, and positive orientation was described.

Methods

The study included 150 women on day 0 after their CC. The measurement of anxiety concerning verticalization, pain, and also negative and positive emotions was conducted twice. During the first measurement, variables such as anxiety levels as a constant disposition, level of pain resistance and positive orientation were also monitored.

Results

Patients upon arrival at the post-operative room declared a higher level of anxiety of verticalization (p < 0.05) (Median = 4; IQR = 5) when compared to 6 h after surgery (Median = 3; IQR = 4). A weak correlation of anxiety and pain was noted (r = 0.264; p < 0.01) in the second measurement. In both measurements, negative emotions and pain resistance proved to be the strongest variables explaining anxiety concerning verticalization.

Conclusions

Low levels of pain experienced by a patient after CC do not explain the variance in anxiety of verticalization. The use of the Numerical Rating Scale (NRS) of anxiety allows care givers to gain patients' psychological perspective in different moments after CC.

Non-Clinical Variables Influencing Cesarean Section Rate According to Robson Classification

Background and Objectives: The incidence of cesarean section (CS) has progressively increased worldwide, without any proven benefit to either the mother or the newborn. The aim of this study was to evaluate the association between CS rates and both clinical and non-clinical variables, while applying the Robson classification system. Materials and Methods: This is a retrospective observational study of pregnant women delivering at a tertiary care hospital between 2012 and 2017, either under public or private healthcare. The overall CS rate, and the elective and non-elective CS rate, divided by classes of Robson, were determined. The rate of vaginal deliveries and CSs was compared between the public and private setting. The distribution of incidence of non-elective CSs and their main indications were analyzed between daytime and nighttime. Results: 18,079 patients delivered during the study period: 69.2% delivered vaginally and 30.8% by CS. Robson class 5 was the most frequent (23.4%), followed by class 2B (16.8%). Of the 289 private practice deliveries, 59.2% were CSs. The CS rate was significantly higher in private compared to public practice: 59.2% and 30.4%, respectively (OR 3.32, 95% CI 2.62 ± 4.21). When only considering elective CSs, a statistically significant difference was found in Robson class 5 between private and public practice, with the latter having more CSs (94.2% and 83.8%, respectively (p = 0.046)). The rate of non-elective CS was significantly lower during nighttime than during daytime (17.2% vs. 21.5%, p < 0.01). During daytime, the higher incidence of CS occurred between 4:00 and 4:59 pm, and during nighttime between 9:00 and 9:59 pm. Failed induction was significantly more common as an indication to CS during daytime when compared to nighttime (p = 0.01). Conclusions: This study identified two non-clinical variables that influenced the CS rate: the type of healthcare setting (private vs. public) and the time of the day. We believe that these indications might be related more to the practitioner attitude, rather than objective delivery complications.

Evaluation of cesarean delivery rates at three university hospital labor units using the Robson classification system

OBJECTIVE

To analyze the frequency of cesarean delivery using the Robson 10-group classification.

METHODS

A multicenter retrospective cohort study was conducted at three university hospital labor units in the Slovak Republic. The medical records of all women who gave birth at these centers from January 1 to December 31, 2017, were assessed.

RESULTS

In all, 1437 of 3361 (42.8%), 729 of 2795 (26.1%), and 303 of 2080 (14.6%) births recorded at the three centers during the current study period were by cesarean delivery. Among the nulliparous term singleton vertex deliveries (Robson group 1 and 2), the frequency of cesarean delivery at the three centers was 613 of 1653 (37.1%), 278 of 1389 (20.0%), and 91 of 898 (10.1%). Among term multiparas with one fetus in a cephalic position and at least one previous cesarean delivery (Robson group 5), the frequency of cesarean delivery at the three centers was 405 of 418 (96.9%), 261 of 343 (76.1%), and 55 of 115 (47.8%).

CONCLUSION

Analysis of the frequency of cesarean delivery by Robson classification could help to identify possibilities for safely decreasing cesarean delivery rates in the clinic. Robson groups 1, 2, and 5 were the most modifiable groups.

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.