The Robson classification has become a global standard for comparing and monitoring cesarean delivery (CD) rates across populations and over time; however, this classification does not account for differences in important maternal, fetal, and obstetric practice factors known to impact CD rates. The objectives of our study were to identify subgroups of women contributing to differences in the CD rate in Sweden and British Columbia (BC), Canada using the Robson classification and to estimate the contribution of maternal, fetal/infant, and obstetric practice factors to differences in CD rates between countries and over time.
Methods and findings
We conducted a population-based cohort study of deliveries in Sweden (January 1, 2004 to December 31, 2016; n = 1,392,779) and BC (March 1, 2004 to April 31, 2017; n = 559,205). Deliveries were stratified into Robson categories and the CD rate, relative size of each group and its contribution to the overall CD rate were compared between the Swedish and the Canadian cohorts. Poisson and log-binomial regression were used to assess the contribution of maternal, fetal, and obstetric practice factors to spatiotemporal differences in Robson group-specific CD rates between Sweden and BC.
Nulliparous women comprised 44.8% of the study population, while women of advanced maternal age (≥35 years) and women with overweight/obesity (≥25 kg/m2) constituted 23.5% and 32.4% of the study population, respectively. The CD rate in Sweden was stable at approximately 17.0% from 2004 to 2016 (p for trend = 0.10), while the CD rate increased in BC from 29.4% to 33.9% (p for trend < 0.001). Differences in CD rates between Sweden and BC varied by Robson group, for example, in Group 1 (nullipara with a term, single, cephalic fetus with spontaneous labor), the CD rate was 8.1% in Sweden and 20.4% in BC (rate ratio [RR] for BC versus Sweden = 2.52, 95% confidence interval [CI] 2.49 to 2.56, p < 0.001) and in Group 2 (nullipara, single, cephalic fetus, term gestation with induction of labor or prelabor CD), the rate of CD was 37.3% in Sweden and 45.9% in BC (RR = 1.23, 95% CI 1.22 to 1.25, p < 0.001). The effect of adjustment for maternal characteristics (e.g., age, body mass index), maternal comorbidity (e.g., preeclampsia), fetal characteristics (e.g., head position), and obstetric practice factors (e.g., epidural) ranged from no effect (e.g., among breech deliveries; Groups 6 and 7) to explaining up to 5.2% of the absolute difference in the CD rate (Group 2: adjusted CD rate in BC 40.7%, adjusted RR = 1.09, 95% CI 1.08 to 1.12, p < 0.001). Adjustment also explained a substantial fraction of the temporal change in CD rates among some Robson groups in BC. Limitations of the study include a lack of information on intrapartum details, such as labor duration as well as maternal and perinatal outcomes associated with the observed differences in CD rates.
In this study, we found that several factors not included in the Robson classification explain a significant proportion of the spatiotemporal difference in CD rates in some Robson groups. These findings suggest that incorporating these factors into explanatory models using the Robson classification may be useful for ensuring that public health initiatives regarding CD rates are evidence informed.
Why was this study done?
- The Robson classification system is a World Health Organization (WHO)-endorsed global standard for comparing and monitoring cesarean delivery (CD) rates.
- This classification does not include important maternal, fetal, and obstetric practice factors known to influence CD rates.
- The contribution of these characteristics to CD rate comparisons between and within populations has been identified as a key deficiency of this classification scheme and has not been comprehensively quantified.
What did the researchers do and find?
- We conducted a population-based cohort study including 1,951,984 deliveries in Sweden and Canada between 2004 and 2016 to assess differences in CD rates among Robson groups, between countries and over time, with and without adjustment for maternal, fetal, and obstetric practice factors.
- The effect of adjustment between countries varied by Robson group from having no effect in some groups to explaining up to 61% of the variation in CDs in others.
- Adjustment for maternal, fetal, and obstetric practice factors explained a substantial fraction of the temporal change in CD rates among some Robson groups in Canada but had little impact on temporal changes in CD rates among Robson groups in Sweden.
What do these findings mean?
- Public health initiatives based on Robson-classified CD rates may be misinformed without a comprehensive consideration of relevant maternal, obstetric practice, and fetal factors.
- Comprehensive and accurate perinatal data collection beyond the Robson criteria is necessary to ensure policies regarding CD rates are suitably evidence informed and prioritized.
- Future studies are warranted to evaluate the differences in CD rates in each Robson group in relation to maternal, fetal, and infant morbidity and mortality.