A Systematic Review of the Robson Classification for Caesarean Section: What Works, Doesn't Work and How to Improve It

<div><p>Background</p><p>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.</p><p>Methods</p><p>Four electronic databases were searched. A three-step thematic synthesis approach and a qualitative metasummary method were used.</p><p>Results</p><p>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.</p><p>Conclusions</p><p>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.</p></div

Modifications, adaptations and recommendations for implementing and interpreting the Robson classification according to the authors/users of the 73 articles included in this systematic review, and effect size (the proportion of articles which recommended each of them).

<p>Modifications, adaptations and recommendations for implementing and interpreting the Robson classification according to the authors/users of the 73 articles included in this systematic review, and effect size (the proportion of articles which recommended each of them).</p

Distribution of the 73 articles on Robson's classification according to country of origin.

<p>Distribution of the 73 articles on Robson's classification according to country of origin.</p

Characteristics of 73 studies that reported the use of Robson's classification.

<p>*3 letters, 1 unpublished manuscript</p><p>**1 study with 8 South American countries, 1 study with 9 countries including Oceania, North America and Europe</p><p>***Commentaries and letters</p>#<p>World Bank Income Group Classification <a href="http://data.worldbank.org/about/country-classifications/country-and-lending-groups#Low_income" target="_blank">http://data.worldbank.org/about/country-classifications/country-and-lending-groups#Low_income</a>. Out of 83 as some studies had multiple countries.</p><p><b>^♦</b>Coverage is defined as the number of women included in the classification as a percentage of the total number of women delivered during the study period.</p

Flowchart of the systematic review.

<p>Flowchart of the systematic review.</p

Pros and cons of the Robson classification as experienced and reported by the authors and users in 73 articles included in this systematic review, and effect size (the proportion of articles containing each concept).

<p>Pros and cons of the Robson classification as experienced and reported by the authors and users in 73 articles included in this systematic review, and effect size (the proportion of articles containing each concept).</p

Definitions proposed by users for variables required in the Robson classification.

<p>Definitions proposed by users for variables required in the Robson classification.</p

Latest available data on caesarean section rates by country (not earlier than 2005).

<p>Latest available data on caesarean section rates by country (not earlier than 2005).</p

Global and regional trends in caesarean section, 1990–2014.

<p>Sub-Saharan Africa includes Eastern, Middle, Southern and Western Africa subregions. For the purpose of this graph, a linear interpolation between available data from 1990 and 2014 was calculated. When data for 2014 were not available, the CS rate for the latest year available was used also for all subsequent years up to 2014.</p

Caesarean section rates in 150 countries categorised according to United Nations geographical grouping in 2014^a.

<p>Caesarean section rates in 150 countries categorised according to United Nations geographical grouping in 2014<a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0148343#t001fn001" target="_blank">^a</a>.</p