Erdin Springer, Rebekka

Grylka-Baeschlin, Susanne

Hess, Thomas H.

Pehlke-Milde, Jessica

Prentl, Elke

ZHAW digitalcollection

Viewpoint | Published 16 January 2018 | doi:10.4414/smw.2018.14578Cite this as: Swiss Med Wkly. 2018;148:w14578Availability and accessibility of perinatal data forthe Robson classification of caesarean sections inSwitzerlandGrylka-Baeschlin Susannea, Hess Thomas H.b, Erdin Rebekkaa, Prentl Elkeb, Pehlke-Milde Jessicaaa Zurich University of Applied Science; School of Health Professions, Institute of Midwifery, Winterthur, Switzerlandb Cantonal Hospital of Winterthur, Department of Obstetrics and Gynaecology, Winterthur, SwitzerlandCaesarean section rates in Switzerland of over 33% areamong the highest in Europe [1], which suggests thatstrategies to decrease these rates should be developed. Cae-sarean sections potentially protect mother and child fromharm [2]; however, rates above 9–16% have not beenfound to decrease maternal and perinatal mortality out-comes and are not economically advantageous [3, 4]. Cae-sarean sections, particularly if performed without a clearmedical indication, can be associated with severe maternaland infantile morbidities [5]. The risks of postpartum an-tibiotic treatment for the mother and of admission to theneonatal care unit for the child increased after caesareansections in comparison with vaginal births [5]. Women alsoexperienced lower fecundity after a caesarean section [6].Additionally, being born by caesarean section, especiallyan elective procedure, may potentially affect the microbio-me and the immunological status of the child [7, 8].Accessing the total number of caesarean sections is usuallyeasy, but very often the indications are difficult to defineand to implement consistently, which makes comparisonsbetween sites and countries impossible [2]. In order to de-crease and maintain caesarean section rates, Robson et al.[2] proposed a Multidisciplinary Quality Assurance Pro-gramme involving collection of prelabour, intrapartal andpostpartum information. The authors proposed audits look-ing at the outcomes in a standardised way, as well as a10-group classification of the caesarean sections. Robsonet al. [2] emphasised the importance of collecting datathat are easily available, quality controlled and validated.The 10-group classification is based on three obstetric con-cepts, namely “category of pregnancy”, “previous obstetricrecord” and “course of labour and delivery”,’ as well as on“gestation”, and each concept contains clearly defined pa-rameters. Robson et al. [2] also provided information aboutthe groups in which caesarean section rates should be lowin order to achieve and maintain appropriate caesarean sec-tion rates. However, the classification of caesarean sectionsaccording to Robson’s propositions requires the availabili-ty and accessibility of the necessary information. As a re-sult of the implications of the mode of birth for the lat-er health of mother and child [5] and in order to developstrategies to achieve appropriate caesarean section rates ata national level, there is a necessity to have access to Swissperinatal data that are representative of the whole countryand that are available for everybody. Our aims were, there-fore, to identify the information needed to apply Robson’sclassification and to investigate the availability and acces-sibility of Swiss perinatal data.We used literature and web research, as well as personalcontacts. After researching the perinatal information thatis required to classify the caesarean sections into Robson’s10-group system [2], we investigated the availability andaccessibility of these variables in the national dataset ofthe Federal Statistical Office and in the routinely, but vol-untarily, collected data of the ASF (ArbeitsgemeinschaftSchweizer Frauenkliniken) [9]. It was of special interestto know if the variables necessary for Robson’s classifi-cation [2] were routinely collected. As both maternal andneonatal information for each caesarean section is neededfor Robson’s classification, it was important to assess if allrequired variables were included in the same dataset and, ifnot, if different datasets could be clearly linked. Addition-ally, we investigated whether the data are publicly accessi-ble and if not, what conditions must be fulfilled to obtainaccess to the data.Robson’s classification of caesarean sections requires theavailability of six obstetric history and perinatal character-istics: parity (nulliparous or multiparous), previous uterinescar (e.g., previous caesarean section), completed gesta-tional weeks, pregnancy (single or multiple), fetal presen-tation (cephalic, breech, oblique or transverse) and onsetof labour (none, spontaneous or induced). According to apersonal communication with the Federal Statistical Office(e-mail correspondence with P. Schwab, FSO, 15 February2017), national perinatal data in Switzerland include mostof these variables, but they are partially in the maternal andpartially in the neonatal dataset. Maternal and neonatal da-ta cannot be linked because of the complete anonymisationof both datasets. It is therefore not possible to combine thedata that are necessary to classify the caesarean sectionsaccording to Robson’s propositions. The questionnaire forthe ASF statistics is publicly available in the internet [9].All variables required to classify the caesarean sectionsinto Robson’s groups are collected routinely. InformationCorrespondence:Susanne Grylka-Baeschlin,MSc, PhD cand., ZürcherHochschule fur AngewandteWissenschaften Departe-ment Gesundheit, Tech-nikumstrasse 81, Postfach,CH-8401 Winterthur, su-sanne.grylka[at]zhaw.chSwiss Medical Weekly · PDF of the online version · www.smw.chPublished under the copyright license “Attribution – Non-Commercial – No Derivatives 4.0”.No commercial reuse without permission. See http://emh.ch/en/services/permissions.html.Page 1 of 2collection for the ASF database is, however, voluntary forthe maternity hospitals. In 2008, 50 of 71 hospitals partic-ipated and data from 40% of all cases in Switzerland wereavailable [10]. Private clinics mostly do not participate inthe ASF and their data are therefore not collected and notaccessible.Public availability of national perinatal data is very limitedbecause only a little information is published online(www.bfs.admin.ch). On request, more detailed aggregatedor individual data are accessible for research purposes,with a data protection agreement. Data from the ASF data-base are not publically available. Hospitals have access totheir own data, and students and universities receive accessto overall data, which is fee-based, on request (personalcommunication Dr T. Hess).Contributing voluntarily to the ASF statistics gives hospi-tals the opportunity to classify their caesarean sections anddevelop strategies to decrease caesarean section rates ac-cording to Robson’s proposals [2, 9]. However, this datacollection is incomplete from a national perspective [10].Private clinics do not often contribute to the ASF statisticsand very often have the highest caesarean section rates.The picture that can be presented on the basis of the ASFdatabase is therefore biased with respect to the wholeSwiss situation. This detailed information does not allowconclusions that can be generalised to the whole country.However, it must be emphasised that the ASF databaseis very useful for quality management in the participatinghospitals, and comparisons between individual participat-ing hospitals is possible. The development of strategies toachieve and maintain reasonable caesarean section rates asproposed by Robson et al. [2] is possible on a site levelin the hospitals that participate voluntarily, and has beendone, for example, by the University Hospital of Berne[11].Our enquiries revealed that there is only limited availabili-ty of the Swiss perinatal data that is needed to classify thecaesarean sections in Switzerland according to the Rob-son’s classification system and to monitor the relatedhealth of mother and child. Furthermore, data are not pub-lically accessible. Routine collection of linked maternaland neonatal data at a national level could provide repre-sentative data for the whole country to enable investiga-tion of regional differences and international comparisons.Additionally, national data would be required to monitorfactors that are relevant to the future life of the new-bornchild. Studies investigating the long-term outcomes of in-terventions and complications during the perinatal periodare more frequently carried out in the northern countries,where data from public health systems can be used and da-ta for mother and child are commonly routinely collectedand linked together [7]. The lack of opportunity for long-term follow up of children born under certain conditionsprevents research into the consequences of perinatal in-terventions and health complications. It also prevents evi-dence-based medical and political discussion about mater-nity care systems.Our research was based on web searches and personalcommunication, and might therefore be incomplete. How-ever, as maternity care providers and maternity care re-searchers, we were able to investigate and reflect on thetopic with an in-depth professional understanding of theproblem. We therefore recommend that the limited avail-ability and accessibility of Swiss perinatal data necessitatesurgent efforts to link maternal and neonatal data inSwitzerland on a national level and to make these data pub-lically available.Disclosure statementNo financial support and no other potential conflict of interest relevantto this article was reported.References1 EUROPERISTAT. European Perinatal Health Report, Health and Careof Pregnant Women and Babies in Europe in 2010. 2013. http://www.eu-roperistat.com/images/doc/EPHR2010_w_disclaimer.pdf. (Updated June2017).2 Robson M, Hartigan L, Murphy M. Methods of achieving and maintain-ing an appropriate caesarean section rate. Best Pract Res Clin ObstetGynaecol. 2013;27(2):297–308. doi: http://dx.doi.org/10.1016/j.bpobg-yn.2012.09.004. PubMed.3 Ye J, Zhang J, Mikolajczyk R, Torloni MR, Gülmezoglu AM, BetranAP. Association between rates of caesarean section and maternal andneonatal mortality in the 21st century: a worldwide population-basedecological study with longitudinal data. BJOG. 2016;123(5):745–53.doi: http://dx.doi.org/10.1111/1471-0528.13592. PubMed.4 Betran AP, Torloni MR, Zhang J, Ye J, Mikolajczyk R, Deneux-TharauxC, et al. What is the optimal rate of caesarean section at population lev-el? A systematic review of ecologic studies. Reprod Health.2015;12(1):57. doi: http://dx.doi.org/10.1186/s12978-015-0043-6.PubMed.5 Villar J, Valladares E, Wojdyla D, Zavaleta N, Carroli G, Velazco A, etal.; WHO 2005 global survey on maternal and perinatal health researchgroup. Caesarean delivery rates and pregnancy outcomes: the 2005WHO global survey on maternal and perinatal health in Latin America.Lancet. 2006;367(9525):1819–29. doi: http://dx.doi.org/10.1016/S0140-6736(06)68704-7. PubMed.6 Radin RG, Mikkelsen EM, Rothman KJ, Hatch EE, Sorensen HT, RiisAH, et al. Brief Report: Cesarean Delivery and Subsequent Fecundabili-ty. Epidemiology. 2016;27(6):889–93. doi: http://dx.doi.org/10.1097/EDE.0000000000000553. PubMed.7 Stokholm J, Thorsen J, Chawes BL, Schjørring S, Krogfelt KA, Bøn-nelykke K, et al. Cesarean section changes neonatal gut colonization. JAllergy Clin Immunol. 2016;138(3):881–889.e2. doi: http://dx.doi.org/10.1016/j.jaci.2016.01.028. PubMed.8 Sevelsted A, Stokholm J, Bønnelykke K, Bisgaard H. Cesarean sectionand chronic immune disorders. Pediatrics. 2015;135(1):e92–8. doi:http://dx.doi.org/10.1542/peds.2014-0596. PubMed.9 Arbeitsgemeinschaft Schweizer Frauenkliniken. Erfassungsbogen ASF-Statistik. http://www.sevisa.ch/files/2714/8230/7839/Bogen_D.pdf. (Up-dated June 2017).10 Hess TH. Entwicklungsmöglichkeiten und Voraussetzungen von der Sta-tistik zum Qualitätssicherungsinstrument am Beispiel der ASF-Statistikder Schweizerischen Gesellschaft für Gynäkologie und Geburtshilfe.2008. https://www.ksw.ch/Portaldata/1/Resources/FRA/Dokumente/Masterarbeit_ASF-Statistik_Dr._med._Th._Hess.pdf. (Updated June2017).11 Mueller M, Kolly L, Bauman M, Imboden S, Surbek D. Analysis of cae-sarean section rates over time in a single Swiss centre using a ten-groupclassification system. Swiss Med Wkly. 2014;144:w13921. doi:http://dx.doi.org/10.4414/smw.2014.13921. PubMed.Viewpoint Swiss Med Wkly. 2018;148:w14578Swiss Medical Weekly · PDF of the online version · www.smw.chPublished under the copyright license “Attribution – Non-Commercial – No Derivatives 4.0”.No commercial reuse without permission. See http://emh.ch/en/services/permissions.html.Page 2 of 2

Availability and accessibility of perinatal data for the Robson classification of caesarean sections in Switzerland

Viewpoint | Published 16 January 2018 | doi:10.4414/smw.2018.14578
Cite this as: Swiss Med Wkly. 2018;148:w14578
Availability and accessibility of perinatal data for
the Robson classification of caesarean sections in
Switzerland
Grylka-Baeschlin Susannea, Hess Thomas H.b, Erdin Rebekkaa, Prentl Elkeb, Pehlke-Milde Jessicaa
a Zurich University of Applied Science; School of Health Professions, Institute of Midwifery, Winterthur, Switzerland
b Cantonal Hospital of Winterthur, Department of Obstetrics and Gynaecology, Winterthur, Switzerland
Caesarean section rates in Switzerland of over 33% are
among the highest in Europe [1], which suggests that
strategies to decrease these rates should be developed. Cae-
sarean sections potentially protect mother and child from
harm [2]; however, rates above 9–16% have not been
found to decrease maternal and perinatal mortality out-
comes and are not economically advantageous [3, 4]. Cae-
sarean sections, particularly if performed without a clear
medical indication, can be associated with severe maternal
and infantile morbidities [5]. The risks of postpartum an-
tibiotic treatment for the mother and of admission to the
neonatal care unit for the child increased after caesarean
sections in comparison with vaginal births [5]. Women also
experienced lower fecundity after a caesarean section [6].
Additionally, being born by caesarean section, especially
an elective procedure, may potentially affect the microbio-
me and the immunological status of the child [7, 8].
Accessing the total number of caesarean sections is usually
easy, but very often the indications are difficult to define
and to implement consistently, which makes comparisons
between sites and countries impossible [2]. In order to de-
crease and maintain caesarean section rates, Robson et al.
[2] proposed a Multidisciplinary Quality Assurance Pro-
gramme involving collection of prelabour, intrapartal and
postpartum information. The authors proposed audits look-
ing at the outcomes in a standardised way, as well as a
10-group classification of the caesarean sections. Robson
et al. [2] emphasised the importance of collecting data
that are easily available, quality controlled and validated.
The 10-group classification is based on three obstetric con-
cepts, namely “category of pregnancy”, “previous obstetric
record” and “course of labour and delivery”,’ as well as on
“gestation”, and each concept contains clearly defined pa-
rameters. Robson et al. [2] also provided information about
the groups in which caesarean section rates should be low
in order to achieve and maintain appropriate caesarean sec-
tion rates. However, the classification of caesarean sections
according to Robson’s propositions requires the availabili-
ty and accessibility of the necessary information. As a re-
sult of the implications of the mode of birth for the lat-
er health of mother and child [5] and in order to develop
strategies to achieve appropriate caesarean section rates at
a national level, there is a necessity to have access to Swiss
perinatal data that are representative of the whole country
and that are available for everybody. Our aims were, there-
fore, to identify the information needed to apply Robson’s
classification and to investigate the availability and acces-
sibility of Swiss perinatal data.
We used literature and web research, as well as personal
contacts. After researching the perinatal information that
is required to classify the caesarean sections into Robson’s
10-group system [2], we investigated the availability and
accessibility of these variables in the national dataset of
the Federal Statistical Office and in the routinely, but vol-
untarily, collected data of the ASF (Arbeitsgemeinschaft
Schweizer Frauenkliniken) [9]. It was of special interest
to know if the variables necessary for Robson’s classifi-
cation [2] were routinely collected. As both maternal and
neonatal information for each caesarean section is needed
for Robson’s classification, it was important to assess if all
required variables were included in the same dataset and, if
not, if different datasets could be clearly linked. Addition-
ally, we investigated whether the data are publicly accessi-
ble and if not, what conditions must be fulfilled to obtain
access to the data.
Robson’s classification of caesarean sections requires the
availability of six obstetric history and perinatal character-
istics: parity (nulliparous or multiparous), previous uterine
scar (e.g., previous caesarean section), completed gesta-
tional weeks, pregnancy (single or multiple), fetal presen-
tation (cephalic, breech, oblique or transverse) and onset
of labour (none, spontaneous or induced). According to a
personal communication with the Federal Statistical Office
(e-mail correspondence with P. Schwab, FSO, 15 February
2017), national perinatal data in Switzerland include most
of these variables, but they are partially in the maternal and
partially in the neonatal dataset. Maternal and neonatal da-
ta cannot be linked because of the complete anonymisation
of both datasets. It is therefore not possible to combine the
data that are necessary to classify the caesarean sections
according to Robson’s propositions. The questionnaire for
the ASF statistics is publicly available in the internet [9].
All variables required to classify the caesarean sections
into Robson’s groups are collected routinely. Information
Correspondence:
Susanne Grylka-Baeschlin,
MSc, PhD cand., Zürcher
Hochschule fur Angewandte
Wissenschaften Departe-
ment Gesundheit, Tech-
nikumstrasse 81, Postfach,
CH-8401 Winterthur, su-
sanne.grylka[at]zhaw.ch
Swiss Medical Weekly · PDF of the online version · www.smw.ch
Published under the copyright license “Attribution – Non-Commercial – No Derivatives 4.0”.
No commercial reuse without permission. See http://emh.ch/en/services/permissions.html.
Page 1 of 2
collection for the ASF database is, however, voluntary for
the maternity hospitals. In 2008, 50 of 71 hospitals partic-
ipated and data from 40% of all cases in Switzerland were
available [10]. Private clinics mostly do not participate in
the ASF and their data are therefore not collected and not
accessible.
Public availability of national perinatal data is very limited
because only a little information is published online
(www.bfs.admin.ch). On request, more detailed aggregated
or individual data are accessible for research purposes,
with a data protection agreement. Data from the ASF data-
base are not publically available. Hospitals have access to
their own data, and students and universities receive access
to overall data, which is fee-based, on request (personal
communication Dr T. Hess).
Contributing voluntarily to the ASF statistics gives hospi-
tals the opportunity to classify their caesarean sections and
develop strategies to decrease caesarean section rates ac-
cording to Robson’s proposals [2, 9]. However, this data
collection is incomplete from a national perspective [10].
Private clinics do not often contribute to the ASF statistics
and very often have the highest caesarean section rates.
The picture that can be presented on the basis of the ASF
database is therefore biased with respect to the whole
Swiss situation. This detailed information does not allow
conclusions that can be generalised to the whole country.
However, it must be emphasised that the ASF database
is very useful for quality management in the participating
hospitals, and comparisons between individual participat-
ing hospitals is possible. The development of strategies to
achieve and maintain reasonable caesarean section rates as
proposed by Robson et al. [2] is possible on a site level
in the hospitals that participate voluntarily, and has been
done, for example, by the University Hospital of Berne
[11].
Our enquiries revealed that there is only limited availabili-
ty of the Swiss perinatal data that is needed to classify the
caesarean sections in Switzerland according to the Rob-
son’s classification system and to monitor the related
health of mother and child. Furthermore, data are not pub-
lically accessible. Routine collection of linked maternal
and neonatal data at a national level could provide repre-
sentative data for the whole country to enable investiga-
tion of regional differences and international comparisons.
Additionally, national data would be required to monitor
factors that are relevant to the future life of the new-born
child. Studies investigating the long-term outcomes of in-
terventions and complications during the perinatal period
are more frequently carried out in the northern countries,
where data from public health systems can be used and da-
ta for mother and child are commonly routinely collected
and linked together [7]. The lack of opportunity for long-
term follow up of children born under certain conditions
prevents research into the consequences of perinatal in-
terventions and health complications. It also prevents evi-
dence-based medical and political discussion about mater-
nity care systems.
Our research was based on web searches and personal
communication, and might therefore be incomplete. How-
ever, as maternity care providers and maternity care re-
searchers, we were able to investigate and reflect on the
topic with an in-depth professional understanding of the
problem. We therefore recommend that the limited avail-
ability and accessibility of Swiss perinatal data necessitates
urgent efforts to link maternal and neonatal data in
Switzerland on a national level and to make these data pub-
lically available.
Disclosure statement
No financial support and no other potential conflict of interest relevant
to this article was reported.
References
1 EUROPERISTAT. European Perinatal Health Report, Health and Care
of Pregnant Women and Babies in Europe in 2010. 2013. http://www.eu-
roperistat.com/images/doc/EPHR2010_w_disclaimer.pdf. (Updated June
2017).
2 Robson M, Hartigan L, Murphy M. Methods of achieving and maintain-
ing an appropriate caesarean section rate. Best Pract Res Clin Obstet
Gynaecol. 2013;27(2):297–308. doi: http://dx.doi.org/10.1016/j.bpobg-
yn.2012.09.004. PubMed.
3 Ye J, Zhang J, Mikolajczyk R, Torloni MR, Gülmezoglu AM, Betran
AP. Association between rates of caesarean section and maternal and
neonatal mortality in the 21st century: a worldwide population-based
ecological study with longitudinal data. BJOG. 2016;123(5):745–53.
doi: http://dx.doi.org/10.1111/1471-0528.13592. PubMed.
4 Betran AP, Torloni MR, Zhang J, Ye J, Mikolajczyk R, Deneux-Tharaux
C, et al. What is the optimal rate of caesarean section at population lev-
el? A systematic review of ecologic studies. Reprod Health.
2015;12(1):57. doi: http://dx.doi.org/10.1186/s12978-015-0043-6.
PubMed.
5 Villar J, Valladares E, Wojdyla D, Zavaleta N, Carroli G, Velazco A, et
al.; WHO 2005 global survey on maternal and perinatal health research
group. Caesarean delivery rates and pregnancy outcomes: the 2005
WHO global survey on maternal and perinatal health in Latin America.
Lancet. 2006;367(9525):1819–29. doi: http://dx.doi.org/10.1016/
S0140-6736(06)68704-7. PubMed.
6 Radin RG, Mikkelsen EM, Rothman KJ, Hatch EE, Sorensen HT, Riis
AH, et al. Brief Report: Cesarean Delivery and Subsequent Fecundabili-
ty. Epidemiology. 2016;27(6):889–93. doi: http://dx.doi.org/10.1097/
EDE.0000000000000553. PubMed.
7 Stokholm J, Thorsen J, Chawes BL, Schjørring S, Krogfelt KA, Bøn-
nelykke K, et al. Cesarean section changes neonatal gut colonization. J
Allergy Clin Immunol. 2016;138(3):881–889.e2. doi: http://dx.doi.org/
10.1016/j.jaci.2016.01.028. PubMed.
8 Sevelsted A, Stokholm J, Bønnelykke K, Bisgaard H. Cesarean section
and chronic immune disorders. Pediatrics. 2015;135(1):e92–8. doi:
http://dx.doi.org/10.1542/peds.2014-0596. PubMed.
9 Arbeitsgemeinschaft Schweizer Frauenkliniken. Erfassungsbogen ASF-
Statistik. http://www.sevisa.ch/files/2714/8230/7839/Bogen_D.pdf. (Up-
dated June 2017).
10 Hess TH. Entwicklungsmöglichkeiten und Voraussetzungen von der Sta-
tistik zum Qualitätssicherungsinstrument am Beispiel der ASF-Statistik
der Schweizerischen Gesellschaft für Gynäkologie und Geburtshilfe.
2008. https://www.ksw.ch/Portaldata/1/Resources/FRA/Dokumente/
Masterarbeit_ASF-Statistik_Dr._med._Th._Hess.pdf. (Updated June
2017).
11 Mueller M, Kolly L, Bauman M, Imboden S, Surbek D. Analysis of cae-
sarean section rates over time in a single Swiss centre using a ten-group
classification system. Swiss Med Wkly. 2014;144:w13921. doi:
http://dx.doi.org/10.4414/smw.2014.13921. PubMed.
Viewpoint Swiss Med Wkly. 2018;148:w14578
Swiss Medical Weekly · PDF of the online version · www.smw.ch
Published under the copyright license “Attribution – Non-Commercial – No Derivatives 4.0”.
No commercial reuse without permission. See http://emh.ch/en/services/permissions.html.
Page 2 of 2


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Availability and accessibility of perinatal data for the Robson classification of caesarean sections in Switzerland

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