Classification of cesarean sections among immigrants in Belgium

Robson ten group classification system for Caesarean sections across Europe: A systematic review and meta-analysis

The aim of this systemic review and meta-analysis was to examine the differences in caesarean section rates across European regions and at a country level by utilizing the Robson classification system. The study has compared caesarean rates across European regions using the Robson classification to identify the drivers of caesarean section use. This review shows significant variations in caesarean section rates across European regions, ranging from 16.9 % in Northern Europe to 43.6 % in Southern Europe. There was a higher contribution of previous CS (Robson Group 5), ranging from 51.2 to 95.0 % of CS in this group to overall rates, particularly in Southern Europe (95.0 %), raises concerns about the "domino effect" of primary caesareans. This finding emphasises the critical importance of strategies to reduce primary CS rates.

BACKGROUND

Caesarean section (CS) rates exhibit considerable global variation, reflecting diverse medical practices, cultural attitudes, and healthcare policies. While some regions maintain relatively low rates, others report significantly higher incidences of the procedure. Analysing these differences is crucial for understanding and developing targeted healthcare strategies and ensuring optimal maternal and neonatal outcomes. This review examines differences in CS rates in Europe according to the Robson 10 group classification.

METHODS

We identified articles between January 2000 to June 2023 using MEDLINE/PubMed, CINAHL, EMBASE, Global Index Medicus, Web of Science and Cochrane library. There was no restriction on patient population, except for birth in a country of the European region. We excluded all studies that were conference proceedings and studies reported in a language other than English and Swedish.

FINDINGS

The search generated a total of 1024 studies, out of which 44 were included, encompassing 6,641,615 births. The majority were from Northern (38 %) and Western Europe (33.5 %). CS rates varied markedly across Europe, ranging from 16.9 % in Northern region to 43.6 % in Southern Europe. The highest contribution to CS rates came from Robson Group 5 (previous CS), with contributions ranging from 51.2 % in Northern to 95.0 % in Southern Europe. The mode of birth for Robson Group 6 (nulliparous, breech) was predominately by CS (88.8 % in Northern to 92.5 % in Central-Eastern Europe).

INTERPRETATION

CS rates continue to vary widely across Europe, with the highest rates in Southern and the lowest in Northern Europe. Previous CS and breech presentation were prominent drivers of CS rates. Region-specific strategies are needed to address these diverse factors to minimise accelerating CS rates across Europe.

[Relevance of the transcultural approach to improve the care relationship in the perinatal period]

The international literature review highlights higher neonatal morbimortality in migrant patients and their babies. The explanatory hypotheses include late pregnancy follow-up with difficulty accessing care, language barriers, and different cultural representation in pregnancy support. On the one hand, we propose to explain the cultural factors that can impact the caring relationship during the perinatal period. On the other hand, we set out tools for anthropological and psychological understanding to enhance the sharing of cultural representations around pregnancy follow-up, the needs of a baby, and obstetrical or postnatal complications. The request for a specialised transcultural opinion needs to be more systematic; the transcultural posture is adaptable to each care professional. This requires the professional to address explicitly the impact of culture in care and consider their own cultural distance. Specialised advice is recommended in certain situations of cumulative vulnerability (complex trauma, perinatal depression with cultural coding of symptoms), blockage or refusal of care for cultural reasons and to avoid cultural misunderstandings. We detail two modalities: mediation and a discussion group around cultural issues set up in the maternity ward. The institutional work we propose within the multidisciplinary team in the maternity ward also allows the acquisition of transcultural competencies.

Impact of maternal nationality on caesarean section rate variation in a high-income country

BACKGROUND

Caesarean section (CS) rates have been reported to differ between immigrants and native-born women in high-income countries.

OBJECTIVE

We assessed the CS rate and its relationship with the CS rate in country of nationality and other explanatory factors among women of different nationalities including Qatari women who underwent deliveries at our hospital to generate evidence that will quantify and help explain the observed CS rates in our hospital.

METHODS

In this retrospective cross-sectional study conducted at the second-largest public maternity hospital in Qatar, Al-Wakra Hospital (AWH), data for all births delivered in 2019 were retrieved from the hospital's electronic medical records. The CS rates and the crude and adjusted risks of Caesarean delivery for mothers from each nationality were determined, and the common indications for CS were analyzed based on nationality. The association between nationality and Caesarean delivery was examined using binomial logistic regression analysis, with Qatari women as the reference group. The correlation between CS rate in country of nationality and observed CS rates in Qatar was also examined using Pearson's correlation.

RESULTS

The study population consisted of 4816 births by women of 68 nationalities, of which 4513 births were by women from 25 countries. The highest proportion of deliveries (n-1247, 25.9%) was by Indian women. The frequency of CS was the highest and lowest among Egyptian (49.6%) and Yemeni women (17.9%), respectively. Elective CS was predominantly performed in women of Arab nationalities; the most common indication was a history of previous multiple CSs. Emergency CS was primarily performed in women of Asian and Sub-Saharan African nationalities; the most common indications were failure to progress and fetal distress. For most nationalities, the CS rate in Qatar was associated with those of the countries of nationality.

CONCLUSIONS

The observed CS rates varied widely among women of different nationalities. The variation was influenced by maternal factors and medical indications as well as the CS rates in the country of nationality. We posit that cultural preferences, acculturation, and patient expectations influenced observed findings. More efforts are required to reduce primary CS rates and to help women make the most informed decisions regarding modes of delivery. Key Message: CS rates varied widely among women of different nationalities. The variation was influenced by medical indications, maternal preferences, and CS rate in countries of nationality. The solution to reducing CS rates should be a culturally informed response.

Cesarean Deliveries Among Immigrant and Canadian-Born Women in a Representative Community Population in Canada: A Retrospective Cohort Study

OBJECTIVE

To examine differences in the rate of cesarean delivery between Canadian-born women and immigrants to Canada and by duration of time in Canada and rate of cesarean delivery in their country-of-origin.

METHODS

We used linked data from hospitalization records and the Canadian Community Health Survey for all deliveries after 20 weeks gestation between 2002 and 2017 in Canada (excluding Québec). Odds of cesarean delivery in recent immigrants (<5 y in Canada) and non-recent immigrants (≥5 y in Canada) were compared with those of Canadian-born women using multivariable logistic regression. Immigrants were further categorized using the cesarean delivery rate in their country-of-origin as low (<10%), medium (≥10 to <35%), or high (≥35%).

RESULTS

Of the 53 505 women included, 89% were Canadian-born, 4% were recent immigrants and 7% were non-recent immigrants. Overall, 28.6% of women had a cesarean delivery. After adjusting for medical and socio-economic factors, the odds of cesarean delivery among recent immigrants (OR 1.12; 95% CI 0.95-1.34) and non-recent immigrants (OR 1.11; 95% CI 0.98-1.25) did not differ statistically from those of Canadian-born women. Recent immigrants from countries with lower caesarean delivery rates had higher odds of cesarean delivery (OR 1.34; 95% CI 1.05-1.70), whereas the odds of caesarean for recent immigrants from medium- and high-rate countries did not differ from those of Canadian-born women.

CONCLUSION

After accounting for demographic and medical factors, few differences remained in cesarean delivery rates between immigrants and Canadian-born women. Country-of-origin practices are unlikely to reflect preferences for cesarean delivery in immigrant women in Canada.

Caesarean delivery in a migration context: the role of prior delivery in the host country

Migrant women in industrialised countries experience high caesarean section (CS) rates but little is known about the effect of a previous delivery in the host country. This study set out to investigate this effect among migrant women in France, using data from the DSAFHIR study on healthcare access of migrant women living in emergency housing hotels, collected in the Paris Metropolitan area in 2017. Respondents reported life-long history of deliveries. We focused on deliveries occurring in France in 2000–2017: 370 deliveries reported by 242 respondents. We conducted chi-square tests and multivariate logistic regressions, adjusting for the clustering of deliveries among respondents by computing standard errors allowing for intragroup correlation. Mode of delivery was associated with duration of residence among multiparous women with no prior CS, with a higher CS rate with shorter duration of residence (16% vs. 7%, p = 0.04). In this group, a previous delivery in France was associated with a lower CS rate (5% vs. 16%, p = 0.008). In multivariate analysis, compared with women with previous birth in France, women giving birth in France for the first time had a higher risk of CS, regardless of duration of residence (aOR = 4.0, 95% CI = 1.3–12.1 for respondents with short duration of residence, aOR = 4.7, 95% CI = 1.2–18.0 for respondents with longer duration of residence). Efforts directed at decreasing the CS rate among migrant women should target women giving birth in the host country for the first time.

Differential rates of cesarean delivery by maternal geographical origin: a cohort study in France

BACKGROUND

In many Western countries, higher rates of cesarean have been described among migrant women compared to natives of receiving countries. We aimed to estimate this difference comparing women originating from France and Sub-Saharan Africa (SSA), identify the clinical situations explaining most of this difference and assess whether maternal origin was independently associated with cesarean risk.

METHODS

The PreCARE prospective multicenter cohort study was conducted in 2010-2012 in the north Paris area. Our sample was restricted to 1500 women originating from Sub-Saharan Africa and 2206 from France. Profiles of cesarean section by maternal origin were described by the Robson classification. Independent associations between maternal origin and 1) cesarean before labor versus trial of labor, then 2) intrapartum cesarean versus vaginal delivery were assessed by logistic regression models to adjust for other maternal and pregnancy characteristics.

RESULTS

Rates of cesarean for women originating from France and SSA were 17 and 31%. The Robson 5A category "unique uterine scar, single cephalic ≥37 weeks" was the main contributor to this difference. Within this category, SSA origin was associated with cesarean before labor after adjustment for medical risk factors (adjusted odds ratio [aOR] = 2.30 [1.12-4.71]) but no more significant when adjusting on social deprivation (aOR = 1.45 [0.63-3.31]). SSA origin was associated with cesarean during labor after adjustment for both medical and social factors (aOR = 2.95 [1.35-6.44]).

CONCLUSIONS

The wide difference in cesarean rates between SSA and French native women is mainly explained by the Robson 5A category. Within this group, medical factors alone do not explain the increased risk of cesarean in SSA women.

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.

Effect of maternal origin on the association between maternal height and risk of preterm birth in Belgium: a retrospective observational cohort study

OBJECTIVES

To investigate the effect of maternal origin on the association between maternal height and the risk of preterm birth (PTB).

DESIGN

Retrospective observational cohort study.

SETTING

Two of the three Belgian regions, including Brussels-Capital and Walloon regions.

PARTICIPANTS

A total of 245 204 women spontaneously delivered live singletons between 2009 and 2013. Maternal nationality at the time of birth included Belgium, Congo, French, Italy, Morocco, Poland, Romania and Turkey.

OUTCOMES MEASURES

The outcome variable was spontaneous PTB, defined as childbirth occurring at less than 37 weeks' gestation.

RESULTS

Average height, demographic characteristics and the spontaneous PTB rate differed according to maternal origin, defined as maternal nationality at birth. The pattern of association between maternal height and the risk of PTB was not uniform by maternal nationality at birth. The low maternal height category was associated with a statistically significant increased risk of spontaneous PTB for Belgian (adjusted OR (aOR) 1.23, 95% CI 1.16 to 1.32), Italian (aOR 1.48, 95% CI 1.12 to 1.96) and Polish (aOR 1.76, 95% CI 1.11 to 2.78), respectively. However, this association was not observed for the women from Congo, France, Morocco, Romania and Turkey.

CONCLUSIONS

The association between height and the risk of PTB was modified by maternal nationality, even for mothers from the same region of the world. For example, there was a significant inverse association for the Belgians and Italians but not for French women. Our data suggest that PTB risk assessment should take into account the specific height of maternal origin.

A method to assess obstetric outcomes using the 10-Group Classification System: a quantitative descriptive study

OBJECTIVES

Internationally, the 10-Group Classification System (TGCS) has been used to report caesarean section rates, but analysis of other outcomes is also recommended. We now aim to present the TGCS as a method to assess outcomes of labour and delivery using routine collection of perinatal information.

DESIGN

This research is a methodological study to describe the use of the TGCS.

SETTING

Stavanger University Hospital (SUH), Norway, National Maternity Hospital Dublin, Ireland and Slovenian National Perinatal Database (SLO), Slovenia.

PARTICIPANTS

9848 women from SUH, Norway, 9250 women from National Maternity Hospital Dublin, Ireland and 106 167 women, from SLO, Slovenia.

MAIN OUTCOME MEASURES

All women were classified according to the TGCS within which caesarean section, oxytocin augmentation, epidural analgesia, operative vaginal deliveries, episiotomy, sphincter rupture, postpartum haemorrhage, blood transfusion, maternal age >35 years, body mass index >30, Apgar score, umbilical cord pH, hypoxic-ischaemic encephalopathy, antepartum and perinatal deaths were incorporated.

RESULTS

There were significant differences in the sizes of the groups of women and the incidences of events and outcomes within the TGCS between the three perinatal databases.

CONCLUSIONS

The TGCS is a standardised objective classification system where events and outcomes of labour and delivery can be incorporated. Obstetric core events and outcomes should be agreed and defined to set standards of care. This method provides continuous and available observations from delivery wards, possibly used for further interpretation, questions and international comparisons. The definition of quality may vary in different units and can only be ascertained when all the necessary information is available and considered together.

Effect of planned place of birth on obstetric interventions and maternal outcomes among low-risk women: a cohort study in the Netherlands

BACKGROUND

The use of interventions in childbirth has increased the past decades. There is concern that some women might receive more interventions than they really need. For low-risk women, midwife-led birth settings may be of importance as a counterbalance towards the increasing rate of interventions. The effect of planned place of birth on interventions in the Netherlands is not yet clear. This study aims to give insight into differences in obstetric interventions and maternal outcomes for planned home versus planned hospital birth among women in midwife-led care.

METHODS

Women from twenty practices across the Netherlands were included in 2009 and 2010. Of these, 3495 were low-risk and in midwife-led care at the onset of labour. Information about planned place of birth and outcomes, including instrumental birth (caesarean section, vacuum or forceps birth), labour augmentation, episiotomy, oxytocin in third stage, postpartum haemorrhage >1000 ml and perineal damage, came from the national midwife-led care perinatal database, and a postpartum questionnaire.

RESULTS

Women who planned home birth more often had spontaneous birth (nulliparous women aOR 1.38, 95 % CI 1.08-1.76, parous women aOR 2.29, 95 % CI 1.21-4.36) and less often episiotomy (nulliparous women aOR 0.73, 0.58-0.91, parous women aOR 0.47, 0.33-0.68) and use of oxytocin in the third stage (nulliparous women aOR 0.58, 0.42-0.80, parous women aOR 0.47, 0.37-0.60) compared to women who planned hospital birth. Nulliparous women more often had anal sphincter damage (aOR 1.75, 1.01-3.03), but the difference was not statistically significant if women who had caesarean sections were excluded. Parous women less often had labour augmentation (aOR 0.55, 0.36-0.82) and more often an intact perineum (aOR 1.65, 1.34-2.03). There were no differences in rates of vacuum/forceps birth, unplanned caesarean section and postpartum haemorrhage >1000 ml.

CONCLUSIONS

Women who planned home birth were more likely to give birth spontaneously and had fewer medical interventions.

International migration as a determinant of emergency caesarean

BACKGROUND

High caesarean rates are of concern given associated risks. International migrant women (women born abroad) represent a substantial proportion of women giving birth in high-income countries (HICs) and face social conditions that may exacerbate childbearing health risks. Among migrant women, emergency rather than planned caesareans, tend to be more prevalent. This method of delivery can be stressful, physically harmful and result in an overall negative birth experience. Research establishing evidence of risk factors for emergency caesareans in migrants is insufficient.

AIMS

(1) Describe potential pathways (with a focus on modifiable factors) by which migration, using internationally recommended migration indicators: country of birth, length of time in country, fluency in receiving-country language, migration classification and ethnicity, may lead to emergency caesarean; and (2) propose a framework to guide future research for understanding "potentially preventable" emergency caesareans in migrant women living in HICs.

DISCUSSION

"Potentially preventable" emergency caesareans in migrant women are likely due to several modifiable, interrelated factors pre-pregnancy, during pregnancy and during labour. Migration itself is a determinant and also shapes other determinants. Complications and ineffective labour progress and/or foetal distress and ultimately the decision to perform an emergency caesarean may be the result of poor health (i.e., physiological effects), lack of support and disempowerment (i.e., psychological effects) and sub-optimal care.

CONCLUSION

Understanding the direct and indirect effects of migration on emergency caesarean is crucial so that targeted strategies can be developed and implemented for reducing unnecessary caesareans in this vulnerable population.

Caesarean births among migrant women in high-income countries

High caesarean birth rates among migrant women living in high-income countries are of concern. Women from sub-Saharan Africa and South Asia consistently show overall higher rates compared with non-migrant women, whereas women from Latin America and North Africa/Middle East consistently show higher rates of emergency caesarean. Higher rates are more common with emergency caesareans than with planned caesareans. Evidence regarding risk factors among migrant women for undergoing a caesarean birth is lacking. Research suggests that pathways leading to caesarean births in migrants are complex, and they are likely to involve a combination of factors related to migrant women's physical and psychological health, their social and cultural context and the quality of their maternity care. Migration factors, including length of time in receiving country and migration classification, have an influence on delivery outcome; however, their effects appear to differ by women's country/region of origin.

Caesarean section by immigrants' length of residence in Norway: a population-based study

BACKGROUND

Immigrants to Europe account for a significant proportion of births in a context of rising caesarean rates. We examined the risk of planned and emergency caesarean section (CS) by immigrants' length of residence in Norway, and compared the results with those of non-immigrants.

METHODS

We linked population-based birth registry data to immigration data for first deliveries among 23 147 immigrants from 10 countries and 385 306 non-immigrants between 1990-2009. Countries were grouped as having low CS levels (<16%; Iraq, Pakistan, Poland, Turkey, Yugoslavia, Vietnam) or high CS levels (>22%; the Philippines, Somalia, Sri Lanka, Thailand). Associations between length of residence and planned/emergency CS were estimated as relative risks (RR) with 95% confidence intervals (CI) in multivariable models.

RESULTS

In the immigrant group with low CS levels, planned, but not emergency, CS was independently associated with longer length of residence. Compared with recent immigrants (<1 year), the risk of planned CS was 70% greater among immigrants with residency of 2-5 years (RR 1.70, CI: 1.19-2.42), and twice as high in those with residency of ≥ 6 years. (RR 2.01, CI: 1.28-3.17). Compared with non-immigrants, immigrants in the low group with residency <2 years had lower risk of planned CS, while those with residency >2 years had greater risk of emergency CS. In the high group, the risk of planned CS was similar to non-immigrants, while emergency CS was 51-75% higher irrespective of length of residency.

CONCLUSION

Efforts to improve immigrants' labour outcomes should target subgroups with sustained high emergency caesarean risk.

A systematic review of the Robson classification for caesarean section: what works, doesn't work and how to improve it

BACKGROUND

Caesarean sections (CS) rates continue to increase worldwide without a clear understanding of the main drivers and consequences. The lack of a standardized internationally-accepted classification system to monitor and compare CS rates is one of the barriers to a better understanding of this trend. The Robson's 10-group classification is based on simple obstetrical parameters (parity, previous CS, gestational age, onset of labour, fetal presentation and number of fetuses) and does not involve the indication for CS. This classification has become very popular over the last years in many countries. We conducted a systematic review to synthesize the experience of users on the implementation of this classification and proposed adaptations.

METHODS

Four electronic databases were searched. A three-step thematic synthesis approach and a qualitative metasummary method were used.

RESULTS

232 unique reports were identified, 97 were selected for full-text evaluation and 73 were included. These publications reported on the use of Robson's classification in over 33 million women from 31 countries. According to users, the main strengths of the classification are its simplicity, robustness, reliability and flexibility. However, missing data, misclassification of women and lack of definition or consensus on core variables of the classification are challenges. To improve the classification for local use and to decrease heterogeneity within groups, several subdivisions in each of the 10 groups have been proposed. Group 5 (women with previous CS) received the largest number of suggestions.

CONCLUSIONS

The use of the Robson classification is increasing rapidly and spontaneously worldwide. Despite some limitations, this classification is easy to implement and interpret. Several suggested modifications could be useful to help facilities and countries as they work towards its implementation.