A global reference for caesarean section rates (C‐Model): a multicountry cross‐sectional study

Objective: To generate a global reference for caesarean section (CS) rates at health facilities. Design Cross-sectional study. Setting: Health facilities from 43 countries. Population/Sample Thirty eight thousand three hundred and twenty-four women giving birth from 22 countries for model building and 10 045 875 women giving birth from 43 countries for model testing. Methods: We hypothesised that mathematical models could determine the relationship between clinical-obstetric characteristics and CS. These models generated probabilities of CS that could be compared with the observed CS rates. We devised a three-step approach to generate the global benchmark of CS rates at health facilities: creation of a multi-country reference population, building mathematical models, and testing these models. Main outcome measures: Area under the ROC curves, diagnostic odds ratio, expected CS rate, observed CS rate. Results: According to the different versions of the model, areas under the ROC curves suggested a good discriminatory capacity of C-Model, with summary estimates ranging from 0.832 to 0.844. The C-Model was able to generate expected CS rates adjusted for the case-mix of the obstetric population. We have also prepared an e-calculator to facilitate use of C-Model (www.who.int/ reproductivehealth/publications/maternal_perinatal_health/c-model/en/). Conclusions: This article describes the development of a global reference for CS rates. Based on maternal characteristics, this tool was able to generate an individualised expected CS rate for health facilities or groups of health facilities. With C-Model, obstetric teams, health system managers, health facilities, health insurance companies, and governments can produce a customised reference CS rate for assessing use (and overuse) of CS. Tweetable abstract: The C-Model provides a customized benchmark for caesarean section rates in health facilities and system

WHO Statement on Caesarean Section Rates

World Health OrganizationWHO, UNDP, UNFPA,World Bank Special Programme Res, UNICEF,Dev & Res Training Human Reprod,Dept Repro, CH-1211 Geneva, SwitzerlandUniv Fed Sao Paulo, Sao Paulo Sch Med, Brazilian Cochrane Ctr, Sao Paulo, BrazilUniv Fed Sao Paulo, Sao Paulo Sch Med, Dept Obstet, Sao Paulo, BrazilShanghai Jiao Tong Univ, Sch Med, Shanghai Key Lab Childrens Environm Hlth, Minist Educ,Xinhua Hosp, Shanghai 200030, Peoples R ChinaUniv Fed Sao Paulo, Sao Paulo Sch Med, Brazilian Cochrane Ctr, Sao Paulo, BrazilUniv Fed Sao Paulo, Sao Paulo Sch Med, Dept Obstet, Sao Paulo, BrazilWHO: 001Web of Scienc

WHO Statement on Caesarean Section Rates

World Health OrganizationWHO, UNDP, UNFPA,World Bank Special Programme Res, UNICEF,Dev & Res Training Human Reprod,Dept Repro, CH-1211 Geneva, SwitzerlandUniv Fed Sao Paulo, Sao Paulo Sch Med, Brazilian Cochrane Ctr, Sao Paulo, BrazilUniv Fed Sao Paulo, Sao Paulo Sch Med, Dept Obstet, Sao Paulo, BrazilShanghai Jiao Tong Univ, Sch Med, Shanghai Key Lab Childrens Environm Hlth, Minist Educ,Xinhua Hosp, Shanghai 200030, Peoples R ChinaUniv Fed Sao Paulo, Sao Paulo Sch Med, Brazilian Cochrane Ctr, Sao Paulo, BrazilUniv Fed Sao Paulo, Sao Paulo Sch Med, Dept Obstet, Sao Paulo, BrazilWHO: 001Web of Scienc

What do popular Spanish women's magazines say about caesarean section? A 21-year survey

ObjectivesCaesarean section (CS) rates are increasing worldwide and maternal request is cited as one of the main reasons for this trend. Women's preferences for route of delivery are influenced by popular media, including magazines. We assessed the information on CS presented in Spanish women's magazines.DesignSystematic review.SettingWomen's magazines printed from 1989 to 2009 with the largest national distribution.SampleArticles with any information on CS.MethodsArticles were selected, read and abstracted in duplicate. Sources of information, scientific accuracy, comprehensiveness and women's testimonials were objectively extracted using a content analysis form designed for this study.Main outcome measuresAccuracy, comprehensiveness and sources of information.ResultsMost (67%) of the 1223 selected articles presented exclusively personal opinion/birth stories, 12% reported the potential benefits of CS, 26% mentioned the short-term and 10% mentioned the long-term maternal risks, and 6% highlighted the perinatal risks of CS. the most frequent short-term risks were the increased time for maternal recovery (n=86), frustration/feelings of failure (n=83) and increased post-surgical pain (n=71). the most frequently cited long-term risks were uterine rupture (n=57) and the need for another CS in any subsequent pregnancy (n=42). Less than 5% of the selected articles reported that CS could increase the risks of infection (n=53), haemorrhage (n=31) or placenta praevia/accreta in future pregnancies (n=6). the sources of information were not reported by 68% of the articles.ConclusionsThe portrayal of CS in Spanish women's magazines is not sufficiently comprehensive and does not provide adequate important information to help the readership to understand the real benefits and risks of this route of delivery.Department of Reproductive Health of the World Health OrganizationBrazilian Cochrane Ctr, São Paulo, BrazilUniversidade Federal de São Paulo, Dept Internal Med, São Paulo, BrazilFederac Mujeres Jovenes, Madrid, SpainWHO, Dept Reprod Hlth & Res, CH-1211 Geneva, SwitzerlandUniversidade Federal de São Paulo, Dept Internal Med, São Paulo, BrazilWeb of Scienc

Analysis of caesarean section and neonatal outcome using the Robson classification in a rural district hospital in Tanzania: An observational retrospective study

OBJECTIVE: Caesarean section (CS) rates have increased worldwide in recent decades. In 2015, the WHO proposed the use of the 10-group Robson classification as a global standard for assessing, monitoring and comparing CS rates both within healthcare facilities over time and between them. The aim of this study was to assess the pattern of CS rates according to the Robson classification and describe maternal and perinatal outcomes by group at the Tosamaganga Hospital in rural Tanzania. DESIGN: Observational retrospective study. SETTING: St. John of the Cross Tosamaganga Hospital, a referral centre in rural Tanzania. PARTICIPANTS: 3012 women who gave birth in Tosamaganga Hospital from 1 January to 30 June 2014 and from 1 March to 30 November 2015. RESULTS: The overall CS rate was 35.2%, and about 90% of women admitted for labour were in Robson groups 1 through 5. More than 40% of the CS carried out in the hospital were performed on nulliparous women at term with a single fetus in cephalic presentation (groups 1 and 3), and the most frequent indication for the procedure was previous uterine scar (39.2%). The majority of severe neonatal outcomes were observed in groups 1 (27.7%), 10 (24.5%) and 3 (19.1%). CONCLUSION: We recorded a high CS rate in Tosamaganga Hospital, particularly in low-risk patients groups (Robson groups 1 and 3). Our analysis of Robson classification and neonatal outcomes suggests the need to improve labour management at the hospital and to provide timely referrals in order to prevent women from arriving there in critical conditions

WHO Statement on Caesarean Section Rates

In 1985 when a group of experts convened by the World Health Organization in Fortaleza, Brazil, met to discuss the appropriate technology for birth, they echoed what at that moment was considered an unjustified and remarkable increase of caesarean section (CS) rates worldwide.1 Based on the evidence available at that time, the experts in Fortaleza concluded: ‘there is no justification for any region to have a caesarean section rate higher than 10–15%’.1 Over the years, this quote has become ubiquitous in scientific literature, being interpreted as the ideal CS rate. Although this reference range was intended for ‘populations’, which are defined by geopolitical boundaries, in many instances it has been mistakenly used as the measurement for healthcare facilities regardless of their complexity or other characteristics. In addition to the case mix of the obstetric population served, the use of CS at healthcare facilities is also affected by factors such as their capacity to handle cases, availability of resource and the clinical management protocols used locally

Vulnerabilities and reparative strategies during pregnancy, childbirth, and the postpartum period:moving from rhetoric to action

Maternal outcomes throughout pregnancy, childbirth, and the postnatal period are influenced by interlinked and interdependent vulnerabilities. A comprehensive understanding of how various threats and barriers affect maternal and perinatal health is critical to plan, evaluate and improve maternal health programmes. This paper builds on the introductory paper of the Series on the determinants of maternal health by assessing vulnerabilities during pregnancy, childbirth, and the postnatal period. We synthesise and present the concept of vulnerability in pregnancy and childbirth, and map vulnerability attributes and their dynamic influence on maternal outcomes in early and late pregnancy and during childbirth and the postnatal period, with a particular focus on low-income and middle-income countries (LMICs). We summarise existing literature and present the evidence on the effects of various reparative strategies to improve pregnancy and childbirth outcomes. Lastly, we discuss the implications of the identified vulnerability attributes and reparative strategies for the efforts of policymakers, healthcare professionals, and researchers working towards improving outcomes for women and birthing people in LMICs

Classifications for Cesarean Section: A Systematic Review

Background: Rising cesarean section (CS) rates are a major public health concern and cause worldwide debates. To propose and implement effective measures to reduce or increase CS rates where necessary requires an appropriate classification. Despite several existing CS classifications, there has not yet been a systematic review of these. This study aimed to 1) identify the main CS classifications used worldwide, 2) analyze advantages and deficiencies of each system.Methods and Findings: Three electronic databases were searched for classifications published 1968-2008. Two reviewers independently assessed classifications using a form created based on items rated as important by international experts. Seven domains (ease, clarity, mutually exclusive categories, totally inclusive classification, prospective identification of categories, reproducibility, implementability) were assessed and graded. Classifications were tested in 12 hypothetical clinical case-scenarios. From a total of 2948 citations, 60 were selected for full-text evaluation and 27 classifications identified. Indications classifications present important limitations and their overall score ranged from 2-9 (maximum grade = 14). Degree of urgency classifications also had several drawbacks (overall scores 6-9). Woman-based classifications performed best (scores 5-14). Other types of classifications require data not routinely collected and may not be relevant in all settings (scores 3-8).Conclusions: This review and critical appraisal of CS classifications is a methodologically sound contribution to establish the basis for the appropriate monitoring and rational use of CS. Results suggest that women-based classifications in general, and Robson's classification, in particular, would be in the best position to fulfill current international and local needs and that efforts to develop an internationally applicable CS classification would be most appropriately placed in building upon this classification. the use of a single CS classification will facilitate auditing, analyzing and comparing CS rates across different settings and help to create and implement effective strategies specifically targeted to optimize CS rates where necessary.Universidade Federal de São Paulo, Dept Obstet, São Paulo, BrazilBrazilian Cochrane Ctr, São Paulo, BrazilWorld Hlth Org, Dept Reprod Hlth & Res, Geneva, SwitzerlandWorld Hlth Org, Dept Knowledge Management & Sharing, Geneva, SwitzerlandUniversidade Federal de São Paulo, Dept Obstet, São Paulo, BrazilWeb of Scienc

Use of the Robson classification to assess caesarean section trends in 21 countries: a secondary analysis of two WHO multicountry surveys

Background: Rates of caesarean section surgery are rising worldwide, but the determinants of this increase, especially in low-income and middle-income countries, are controversial. In this study, we aimed to analyse the contribution of specific obstetric populations to changes in caesarean section rates, by using the Robson classification in two WHO multicountry surveys of deliveries in health-care facilities. The Robson system classifies all deliveries into one of ten groups on the basis of five parameters: obstetric history, onset of labour, fetal lie, number of neonates, and gestational age. Methods: We studied deliveries in 287 facilities in 21 countries that were included in both the WHO Global Survey of Maternal and Perinatal Health (WHOGS; 2004–08) and the WHO Multi-Country Survey of Maternal and Newborn Health (WHOMCS; 2010–11). We used the data from these surveys to establish the average annual percentage change (AAPC) in caesarean section rates per country. Countries were stratified according to Human Development Index (HDI) group (very high/high, medium, or low) and the Robson criteria were applied to both datasets. We report the relative size of each Robson group, the caesarean section rate in each Robson group, and the absolute and relative contributions made by each to the overall caesarean section rate. Findings: The caesarean section rate increased overall between the two surveys (from 26·4% in the WHOGS to 31·2% in the WHOMCS, p=0·003) and in all countries except Japan. Use of obstetric interventions (induction, prelabour caesarean section, and overall caesarean section) increased over time. Caesarean section rates increased across most Robson groups in all HDI categories. Use of induction and prelabour caesarean section increased in very high/high and low HDI countries, and the caesarean section rate after induction in multiparous women increased significantly across all HDI groups. The proportion of women who had previously had a caesarean section increased in moderate and low HDI countries, as did the caesarean section rate in these women. Interpretation: Use of the Robson criteria allows standardised comparisons of data across countries and timepoints and identifies the subpopulations driving changes in caesarean section rates. Women who have previously had a caesarean section are an increasingly important determinant of overall caesarean section rates in countries with a moderate or low HDI. Strategies to reduce the frequency of the procedure should include avoidance of medically unnecessary primary caesarean section. Improved case selection for induction and prelabour caesarean section could also reduce caesarean section rates