Analysis of Caesarean Section Rates Using the Robson Ten-group Classification at a Tertiary Care Teaching Hospital in Eastern India: A Cross-sectional Study

DOI: 10.7860/JCDR/2021/46668.14676 Original Article Obstetrics and Gynaecology Section Analysis of Caesarean Section Rates Using the Robson Ten-group Classification at a Tertiary Care Teaching Hospital in Eastern India: A Cross-sectional Study Hiralal Konar1, Madhutandra Sarkar2, Sisir Kumar Chowdhury3 ABSTRACT Introduction: The Robson ten-group classification identifies the women’s groups that make the greatest contribution to the overall rate of Caesarean Section (CS), and thereby helps to optimise CS rates. It also helps to ensure optimum maternal and perinatal outcomes. Aim: To examine the rates of CS using the Robson ten-group classification, and also to identify the women’s groups that contribute most to CS rates in a tertiary care teaching and referral hospital in Kolkata, India. Materials and Methods: This cross-sectional observational study was conducted over a period of one year from May 2012 to April 2013. All pregnant women admitted under the supervision of a particular unit of the Department of Obstetrics and Gynaecology and delivered in that hospital during the study period were included. Necessary data collection was done on the following parameters, i.e., previous obstetric history, category of pregnancy, course of labour and delivery, and gestational age. The women were categorised into the ten Robson groups. For each group, the CS rate, relative size of the group, and the percentage contribution made by the group to the overall CS rate were calculated and expressed in percentages. Chi-square test, Z-test and the trial version of Statistical Package for Social Sciences (SPSS) version 20.0 were used to analyse the data. Results: The CS rate in the present study was 43.13% (735 out of 1704 deliveries). Not only the largest group in terms of relative size 649 (38.08%), the Robson group 1 had a CS rate of 41.75% (271/649), as well as the largest absolute number of caesarean deliveries. The group 1 made the largest contribution (271) to the overall CS rate (15.9%). The group 5 was the second largest contributing group 155 (9.09%), followed by group 3 96 (5.63%) and group 2 69 (4.04%). In the present study group 5 showed the CS rate of 95.67%, group 3 with CS rate of 24.48% and group 2 with CS rate of 60.52%. Conclusion: The Robson groups 1, 2, 3 and 5 were found to be the major contributors to the overall CS rate. These groups may be targeted for effective interventions to reduce the CS rate. Active management of labour in a primigravida with spontaneous onset, reduction of primary caesarean delivery, promoting vaginal birth after CS, and careful assessment of cases before induction of labour in nulliparous women, are likely to be few effective strategies. Keywords: Caesarean section rate, India, Robson classification women’s groups INTRODUCTION The Caesarean Section (CS) rates continue to rise steadily worldwide over the past few decades in both developed and developing countries. The major driving forces of this trend are still unclear and quite controversial [1]. The consequences are also not clearly understood. Increasing caesarean birth rates are associated with high maternal and neonatal complications and consequent increased health care costs. It is an issue of growing public health concern worldwide [2]. The World Health Organisation (WHO) in 1985 suggested that the CS rates should not exceed 15% in any region [3]. However, the CS rates increased from 6.7% in 1990 to 19.1% in 2014 worldwide (increase by 12.4 percent with an Average Annual Rate of Increase (AARI) of 4.4 percent) [2]. Moreover, the CS rates vary worldwide. Latest estimates show highest rate in Latin America and the Caribbean (42.2%), followed by Oceania (32.6%), Northern America (32.3%), Europe (25.0%), Asia (19.5%) and Africa (7.4%) [2]. In the United States, the CS rate in 2016 was 31.9% [4]. According to the National Family Health Survey (NFHS) data, the CS rate in India has increased from 2.9 percent of the childbirth in 1992-93 (NFHS 1) to 17.2 percent in 2015-16 (NFHS 4) with an AARI of 8 percent. The CS rate is 23.8 percent in the state of West Bengal in Eastern India [5]. “The WHO proposes the use of Robson ten-group classification system as the global standard for assessing, monitoring and 24 comparing CS rates within healthcare facilities over time and between facilities” [6]. Robson proposed this classification in 2001 to examine CS within mutually exclusive groups of women with particular obstetric characteristics (rather than the indication for CS). Most importantly, this classification identifies groups that make the greatest contribution to the overall rate of CS, and thereby helps to create and implement effective strategies specifically targeted to optimise CS rates. It also helps to ensure optimum maternal and perinatal outcomes [7]. With the above background, the present study was undertaken with the following objectives: 1. 2. To examine the rates of CS using the Robson ten-group classification system at a tertiary care teaching and referral hospital in kolkata, India. To identify the groups within the obstetric population that contribute most to CS rates and thus to examine the applicability of the Robson classification system in a setting which caters a good fraction of referral cases. MATERIALS AND METHODS A Hospital-based cross-sectional descriptive study was carried out in the Department of Obstetrics and Gynaecology, Calcutta National Medical College and Hospital, a tertiary care teaching and referral hospital in Kolkata, West Bengal, India from May 2012 to April 2013. Journal of Clinical and Diagnostic Research. 2021 Mar, Vol-15(3): QC24-QC28 www.jcdr.net Hiralal Konar et al., Analysis of CS Rates Using the Robson Ten-group Classification Ethical clearance for doing this study was obtained from the Institutional Ethics Committee (No. CNMC/ETHI/46, dated 03.01.2012). Informed consent to participate in the study was obtained from all the eligible women. Overall, 1704 women were included in the study. Inclusion criteria: All pregnant women admitted under the supervision of the Unit-2 of the Department of Obstetrics and Gynaecology and delivered in the above-mentioned hospital. The obstetric characteristics as described in the Robson classification [8] were considered, i.e., parity, onset of labour, gestational age, foetal presentation and number of fetuses. Analysis of the hospital records revealed that, the overall CS rate in this hospital increased from 33.29% to 40.4%, an increase of 7% over a period of 4 years including the period of present study (20122013) and its preceding three years (2009-2010, 2010-2011, and 2011-2012). At the same time, the rate of vaginal delivery decreased from 66.71% to 59.6%. This trend was found to be statistically significant (χ2 for linear trend=82.46, p-value ≤0.001) [Table/Fig-2]. Vaginal delivery (%) Caesarean delivery (%) May 2009-April 2010 5753 (66.71) 2871 (33.29) Exclusion criteria: Women with inc (...truncated)