Caesarean section rates from Malaysian tertiary hospitals using Robson’s 10-group classification

Karalasingam et al. BMC Pregnancy and Childbirth https://doi.org/10.1186/s12884-020-2760-2 (2020) 20:64 RESEARCH ARTICLE Open Access Caesarean section rates from Malaysian tertiary hospitals using Robson’s 10-group classification Shamala Devi Karalasingam1* , Ravichandran Jeganathan2, Ravindran Jegasothy3 and Daniel D. Reidpath4,5 Abstract Background: Rising caesarean section rates is a concern worldwide. This study aimed to use Robson’s ten group classification to identify which groups of women were contributing most to the rising caesarean section rates in Malaysian tertiary hospitals and to compare between hospitals, using a common standard set of variables. Methods: A 5-year (2011–2015) cross-sectional study was conducted using data from the Malaysian National Obstetrics Registry (NOR). A total of 608,747 deliveries were recorded from 11 tertiary state hospitals and 1 tertiary hospital from the Federal territory. Results: During the study period, there were 141,257 Caesarean sections (23.2%). Caesarean sections in Group 1 (nulliparous term pregnancy in spontaneous labour) and Group 3 (multiparous term pregnancy in spontaneous labour) had an increasing trend from 2011 to 2015. The group that contributed most to the overall caesarean section rates was Group 5 (multiparous, singleton, cephalic≥37 weeks with previous caesarean section) and the rates remained high during the 5-year study period. Groups 6, 7 and 9 had the highest caesarean section rates but they made the smallest contribution to the overall rates. Conclusions: Like many countries, the rate of caesarean section has risen over time, and the rise is driven by caesarean section in low-risk groups. There was an important hospital to hospital variation. The rise in caesarean section rates reflects a globally disturbing trend, and changes in policy and training that creates a uniform standard across hospitals should be considered. Keywords: Robson’s classification, Caesarean section, Birth registry Synopsis The rise in Caesarean section (CS) reflects a globally disturbing trend. Changes in policy and training that creates a uniform standard across hospitals should be considered. Background In 1985 the World Health Organization (WHO) set the optimal rate for Caesarean section (CS) at 10–15% of all births [1]; and notwithstanding this ideal, for the last quarter of a century, CS rates have been increasing. A recent review showed a global CS rate around 18.6% with some regional rates above 27.2% [2]. For example, * Correspondence: 1 National Obstetrics Registry, Institute Clinical Research, National Institute of Health, No 1 Jalan Setia Murni U13/52, Seksyen U13, Setai Alam, Shah Alam 40170, Selangor, Malaysia Full list of author information is available at the end of the article in recent years the CS rates in Denmark Ireland, and Turkey, were 20.6, 26, and 42.7% respectively [3]. In Lithuania the CS rates have increased more than 2.5 fold from 9.6% in 1995 to 25% in 2011 [4].The rise in CS rates above the WHO recommendation had been a cause for concern because CS carries inherent risks of mortality and morbidity for both the mother and the baby. If there is an ideal rate, any excess may be indicative of unnecessary medical intervention [2]. In a moderating statement released in 2015, however, WHO stepped back from a fixed, ideal rate and suggested that “every effort should be made to provide caesarean sections to women in need, rather than striving to achieve a specific rate [5]. Determining whether any particular CS is clinically required, is challenging because the decision to perform © The Author(s). 2020 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Karalasingam et al. BMC Pregnancy and Childbirth (2020) 20:64 the procedure often rests on an individual clinical judgement made under significant time constraints. Given that the rate of clinically required CS may vary for demographic reasons between populations. However, one would, on average, expect a similar rate of CS within similar subsets of the same population, with the reasons for CS varying over time [6]. An analysis of Malaysian tertiary hospital data, however, showed substantial variation in CS rates (not accounted for by demographic variation) from as low as 16% to more than 32% [7, 8]. This kind of variation within the context of a single hospital system within one country is a cause for potential concern and invites investigation [9]. Attempts to classify CS has led to 27 separate classificatory systems based on various factors. Factors included (i) clinical indications “such as dystocia, acute intrapartum fetal distress”, (ii) a clinical judgment about the degree of urgency, (iii) features about the mother such as parity or a previous history of CS, and (iv) other approaches including an evaluation of staffing. A recent systematic review of CS classificatory systems concluded that the Robson’s classification provided the best method for collecting useful comparative data [5]. Robson’s classification accounts for fetal presentation, the number of previous pregnancies, the course of the delivery, and gestational age [10]. The system is simple to implement, provides comparable data between settings and over time, and allows for an analysis of the indicators of CS. The approach has been used widely since its publication in 2001 [10]. Recently it has been applied in small pilot settings involving a single small hospital through to larger national studies involving multiple hospitals [11]. It has never been applied to Malaysian data and rarely involving the number of births recorded in the Malaysian National Obstetrics Registry [7, 8]. Given the disparity in observed hospital CS rates, and the potential to look at changes over time, such an analysis would be timely; and could identify settings where further effort is required to address the CS rate. Methods The Malaysian NOR is a register of births in government tertiary hospitals established in July 2009. It has become one of the world’s largest active birth registries recording maternal details, previous obstetric history, and birth outcomes. The NOR records all births (live births and stillbirths) at ≥22 weeks gestation. A complete description of the NOR can be found in the annual reports [7, 8] and the website [http://www.acrm.org.my/nor/]. Ethical approval for the NOR was provided by the Medical Research and Ethics Committee of the Ministry of Health, M (...truncated)