In e na ional Jou nal o
En i onmen al Resea ch
and Public Heal h
A icle
Analysis o Caesa ean Sec ion Ra es Using he
Robson Classi ica ion Sys em a a Uni e si y
Hospi al in Spain
Ra ael Vila-Candel 1,2,* , Anna Ma ín3,4, Ramón Escu ie 4, En ique Cas o-Sánchez 5and
F ancisco Ja ie So iano-Vidal 2,6
1
Depa men o Obs e ics and Gynaecology, Hospi al Uni e si a io de la Ribe a, FISABIO. C a. Co be a km
1, 46600 Valencia, Spain
2Depa men o Nu sing, Facul y o Nu sing and Podia y, Uni e si a de València, Jaume Roig, s/n,
46010 Valencia, Spain; [email p o ec ed]
3School o Medicine, Uni e sidad Au ónoma de Mad id, Spain. C/A zobispo Mo cillo 4, 28029 Mad id,
Spain; [email p o ec ed]
4School o Heal h Sciences Blanque na, Uni e si a Ramon Llull, C/Padilla 326, 08025 Ba celona, Spain;
[email p o ec ed]
5NIHR Heal h P o ec ion Resea ch Uni (HPRU) in Heal hca e Associa ed In ec ions (HCAI) and
An imic obial Resis ance (AMR) a Impe ial College London, Du Cane Road, London W12 0NN, UK;
[email p o ec ed]
6Depa men o Obs e ics and Gynaecology, Hospi al Lluis Alcanyis, FISABIO. C a Xà i a, s/n, 46800
Valencia, Spain
*Co espondence: [email p o ec ed]
Recei ed: 8 Janua y 2020; Accep ed: 26 Feb ua y 2020; Published: 29 Feb ua y 2020
Abs ac :
Backg ound: The WHO ecommends he use o he Robson en-g oup classi ica ion sys em
(RTGCS) as an e ec i e moni o ing and analysis ool o assess he use o caesa ean sec ions (CS).
The p esen s udy aimed o conduc an analysis o bi hs using he RTGCS in La Ribe a Uni e si y
Hospi al o e nine yea s and o assess he le els and ends o CS bi hs. Me hods: Re ospec i e
s udy be ween Janua y 1, 2010, and Decembe 31, 2018. All eligible women we e alloca ed in RTGCS
o de e mine he absolu e and ela i e con ibu ion made by each g oup o he o e all CS a e; linea
eg ession and weigh ed leas squa es eg ession analysis we e used o analyze ends o e ime. The
isk o CS o women wi h induced e sus spon aneous onse o labo was calcula ed wi h an odds
a io (OR) wi h a 95% CI. Resul s: 16,506 women ga e bi h du ing he s udy pe iod, 19% o hem by
CS. O e all, 20.4% o women we e in g oup 1 (nullipa ous, single on cephalic, e m, spon aneous
labo ), 29.4% in g oup 2 (nullipa ous, single on cephalic, e m, induced labo o caesa ean be o e
labo ), and 12.8% in g oup 4 (mul ipa ous, single on cephalic, e m, induced o caesa ean deli e y
be o e labo ) made he mos signi ican con ibu ions o he o e all a e o CS; Conclusions: In ou
s udy, Robson G oups 1, 2, and 4, we e iden i ied as he main con ibu o s o he hospi al’s o e all
CS a e. The RTGCS p o ides an easy way o collec ing in o ma ion abou he CS a e, is a aluable
clinical me hod ha allows s anda dized compa ison o da a, and ime poin , and iden i ies he
g oups d i ing changes in CS a es.
Keywo ds:
caesa ean sec ion; Robson en-g oup classi ica ion sys em; labo ; deli e y
classi ica ion; Spain
1. Backg ound
The e is g owing in e na ional conce n abou he inc eased use o caesa ean sec ions (CS),
pa icula ly in high-income coun ies [
1
]. Caesa ean p ocedu es pe o med in he absence o a clinical
In . J. En i on. Res. Public Heal h 2020,17, 1575; doi:10.3390/ije ph17051575 www.mdpi.com/jou nal/ije ph
In . J. En i on. Res. Public Heal h 2020,17, 1575 2 o 12
jus i ica ion do no educe ma e nal o in an dea h a es i ca ied ou a a a e highe han 10%–15% [
2
].
The unjus i ied, excessi e use o clinical p ocedu es can lead o an e e -inc easing he apeu ic cascade
o a oidable in e en ions [
3
] and become li e- h ea ening in he p esen o u u e p egnancies o
bo h he women and child en [
4
]. The wo ldwide ise in CS a es has become a g owing public heal h
conce n and a cause o deba e due o po en ial ma e nal and pe ina al isks, cos issues, and inequi y
in access [5].
The e is a high deg ee o a iabili y in he epo ed c ude a es o CS pe o med in di e en
coun ies and egions, and he e a e o en e en signi ican di e ences be ween hospi als wi hin a single
egion. The highes caesa ean a es a e obse ed in he Dominican Republic (56.4%), B azil (55.6%),
and Egyp (51.8%), wi h A ica (7.3%) showing he lowes p opo ion o hese p ocedu es [
1
]. In mos
Eu opean coun ies, he a es a e abou 25% o 35% [
5
]. In Spain, he a e age CS a e epo ed ac oss
he 17 au onomous communi ies, he go e ning en i ies independen ly esponsible o heal h ca e [
6
]
and o deploying heal h esou ces o se e he needs o hei local popula ions, was ound o be 24.5%
in 2015 [
7
,
8
]. Howe e , due o he decen alized s uc u e o he heal h sys em, he e is no na ionally
es ablished sys em o moni o he use o caesa ean p ocedu es.
Achie ing educ ions in ma e nal and in an mo bidi y and mo ali y a e, among o he s,
he objec i es p omo ed by he Wo ld Heal h O ganiza ion (WHO) o 2030. One o he sugges ed ways
o mee his goal consis s o a oiding clinically unnecessa y caesa eans [
9
]. Howe e , he challenge
is o keep CS a es low while ensu ing sa e ou comes o mo he s and in an s [
4
]. One o he main
e e ed di icul ies was he lack o a classi ica ion ool ha would be easible o be used in e na ionally,
o allow audi eedback and se ing an op imal CS a e o e coun ies. To add ess his gap, in 2001,
Robson e al. p oposed an o e all classi ica ion me hod ha acili a es an unde s anding o he a e
o CS in a cen e and makes i possible o iden i y key subpopula ion g oups, all in o de o in o m
measu es aimed a p e en ing unnecessa y p ocedu es [10–12].
The WHO has p oposed he use o he Robson en-g oup classi ica ion sys em (RTGCS) as he
global s anda d, as his classi ica ion me hod allows o he analysis o changing ends o e ime,
makes i possible o compa e di e ences be ween cen e s and shed ligh on how changes in clinical
p ac ice can op imize caesa ean a es, hus ensu ing excellence in ma e nal and pe ina al ca e [
13
].
The mo e in-dep h analysis o e ed by his me hod allows us o examine issues such as which g oups
o women and which obs e ic popula ions a e mos likely o unde go caesa ean sec ions, in o ma ion
ha can poin us owa d he kinds o in e en ions ha migh help educe he a es o caesa ean
sec ions, when and whe e such educ ions a e desi able [14].
The p esen s udy aimed o conduc an analysis o bi hs using he RTGCS in La Ribe a Uni e si y
Hospi al o e nine yea s and o assess he le els and ends o CS bi hs.
2. Me hods
2.1. Design, Popula ion, and Sample
An obse a ional s udy was conduc ed o bi hs a La Ribe a Uni e si y Hospi al (LRUH) (Valencia,
Spain) om Janua y 1, 2010, o Decembe 31, 2018. The da a we e e ospec i ely ex ac ed om he
elec onic bi h eco ds o women included o e his pe iod.
The heal h depa men o La Ribe a has a popula ion o 250,000 inhabi an s and a yea ly a e age
o 1700 bi hs. The hospi al manages bi hs om week 34, as below his ges a ional age, women a e
e e ed when app op ia e o he e e ence hospi al o neona al uni suppo i equi ed. The s udy’s
popula ion included women gi ing bi h du ing he s udy pe iod o li e babies a e a leas 24 weeks
ges a ion, o o a li ebo n baby weighing a leas 500 g.
Ou s udy applied he e hical p inciples o medical esea ch es ablished in cu en Spanish
legisla ion and was app o ed by he LRUH Resea ch Commission’s Resea ch E hics Commi ee
(#134-19). Conside a ions such as con iden iali y and ull in o ma ion we e ex ended o all pa icipan s.
In . J. En i on. Res. Public Heal h 2020,17, 1575 3 o 12
2.2. Da a Collec ion Tools
We used he RTGCS o ca ego ize all women gi ing bi h wi h 24 weeks’ ges a ion o longe
du ing ou s udy pe iod [15]. Table 1shows he de ini ions o each g oup.
Table 1. G oup desc ip ion o Robson’s classi ica ion sys em.
1 Nullipa ous, single on cephalic, ≥37 weeks, spon aneous labo .
2a Nullipa ous, single on cephalic, ≥37 weeks, induced labo .
2b Nullipa ous, single on cephalic, ≥37 weeks, o caesa ean deli e y be o e labo .
3 Mul ipa ous, single on cephalic, ≥37 weeks, spon aneous labo .
4a Mul ipa ous, single on cephalic, ≥37 weeks, induced labo .
4b Mul ipa ous, single on cephalic, ≥37 weeks, caesa ean deli e y be o e labo .
5 P e ious caesa ean deli e y, single on cephalic,
≥
37 weeks, spon aneous labo o induced labo o caesa ean deli e y
be o e labo .
6 All nullipa ous single on b eeches, spon aneous labo o induced labo o caesa ean deli e y be o e labo .
7 All mul ipa ous single on b eeches (including p e ious caesa ean deli e y), spon aneous labo o induced labo o
caesa ean deli e y be o e labo .
8 All mul iple p egnancies, spon aneous labo o induced labo o caesa ean deli e y be o e labo .
9 All abno mal single on lies (including p e ious caesa ean deli e y bu excluding b eech), spon aneous labo o
induced labo o caesa ean deli e y be o e labo .
10 All single on cephalic, ≤36 weeks (including p e ious caesa ean deli e y), spon aneous labo o induced labo o
caesa ean deli e y be o e labo .
All women we e con empo aneously classi ied using he i e obs e ic cha ac e is ics desc ibed in
he RTGCS (numbe o e uses, pa i y, e al p esen a ion, he onse o labo , and ges a ional age), wi hou
equi ing he indica ion o CS (Figu e 1). All ca ego ies we e o ally inclusi e and mu ually exclusi e.
In . J. En i on. Res. Public Heal h 2020, 17, 1575 3 o 13
2.2. Da a Collec ion Tools
We used he RTGCS o ca ego ize all women gi ing bi h wi h 24 weeks’ ges a ion o longe
du ing ou s udy pe iod [15]. Table 1 shows he de ini ions o each g oup.
Table 1. G oup desc ip ion o Robson’s classi ica ion sys em.
1 Nullipa ous, single on cephalic, ≥37 weeks, spon aneous labo .
2a Nullipa ous, single on cephalic, ≥37 weeks, induced labo .
2b Nullipa ous, single on cephalic, ≥37 weeks, o caesa ean deli e y be o e labo .
3 Mul ipa ous, single on cephalic, ≥37 weeks, spon aneous labo .
4a Mul ipa ous, single on cephalic, ≥37 weeks, induced labo .
4b Mul ipa ous, single on cephalic, ≥37 weeks, caesa ean deli e y be o e labo .
5 P e ious caesa ean deli e y, single on cephalic, ≥37 weeks, spon aneous labo o induced
labo o caesa ean deli e y be o e labo .
6 All nullipa ous single on b eeches, spon aneous labo o induced labo o caesa ean deli e y
be o e labo .
7 All mul ipa ous single on b eeches (including p e ious caesa ean deli e y), spon aneous labo
o induced labo o caesa ean deli e y be o e labo .
8 All mul iple p egnancies, spon aneous labo o induced labo o caesa ean deli e y be o e
labo .
9 All abno mal single on lies (including p e ious caesa ean deli e y bu excluding b eech),
spon aneous labo o induced labo o caesa ean deli e y be o e labo .
10 All single on cephalic, ≤36 weeks (including p e ious caesa ean deli e y), spon aneous labo
o induced labo o caesa ean deli e y be o e labo .
All women we e con empo aneously classi ied using he i e obs e ic cha ac e is ics desc ibed
in he RTGCS (numbe o e uses, pa i y, e al p esen a ion, he onse o labo , and ges a ional age),
wi hou equi ing he indica ion o CS (Figu e 1). All ca ego ies we e o ally inclusi e and mu ually
exclusi e.
Figu e 1. Flow cha o he Robson en-g oup classi ica ion sys em (RTGCS). Sou ce
h ps://www.who.in / ep oduc i eheal h/publica ions/ma e nal_pe ina al_heal h/ obson-
classi ica ion/en/ [15].
Figu e 1.
Flow cha o he Robson en-g oup classi ica ion sys em (RTGCS). Sou ce h ps://www.who.
in / ep oduc i eheal h/publica ions/ma e nal_pe ina al_heal h/ obson-classi ica ion/en/[15].
A aining session was conduc ed o in oduce he implemen a ion manual o he s a esponsible
o da a collec ion. The in e p e a ion o he da a collec ed in he epo able o he Robson classi ica ion
was ca ied ou acco ding o h ee main domains: quali y o in o ma ion, ype o popula ion, and
caesa ean sec ion a e.
The i e a iables collec ed o RTGCS included obs e ic his o y (pa i y and p e ious caesa ean
sec ion), ype onse o labo (spon aneous, induced, o caesa ean sec ion be o e he onse o labo ), e al
p esen a ion o lie (cephalic, b eech, o ans e se), numbe o neona es, and ges a ional age (p e e m
o e m). O he in o ma ion collec ed o desc ibe popula ion consis ed o sociodemog aphic da a and
he obs e ic cha ac e is ics o he p egnan women: coun y o o igin, age, newbo n’s gende , bi h
weigh , and eeding in he deli e y oom (b eas eeding, o mula eeding).
In . J. En i on. Res. Public Heal h 2020,17, 1575 4 o 12
2.3. S a is ical Analysis
S a is ical analyses we e ca ied ou using SPSS so wa e e sion 20.0 (IBM Co p. Released
2011. IBM SPSS S a is ics o Windows, A monk, NY: IBM Co p.) F equencies and pe cen ages we e
calcula ed o all a iables. The s anda d de ia ion (x
±
SD) o he mean was calcula ed o quan i a i e
a iables. The o e all CS a e, he ela i e size o each g oup, he CS a e wi hin each g oup, and each
g oup’s ela i e and absolu e con ibu ion o he o e all CS a e we e calcula ed o e he s udy pe iod.
The ela i e size o each o he 10 g oups was calcula ed by di iding he numbe o bi hs in each g oup
by he o al numbe o bi hs in he obs e ic popula ion and exp essing i as a pe cen age. The CS
a es we e calcula ed by di iding he numbe o CS by he o al numbe o bi hs in each g oup and
exp essing his igu e as a pe cen age. Finally, he pe cen age con ibu ion made by each g oup o he
o e all CS a e was calcula ed by di iding he numbe o CS in each g oup by he o al numbe o
bi hs in he obs e ic popula ion.
Linea eg ession was pe o med o de e mine he end o e ime in he numbe o deli e ies.
Weigh ed leas squa es (WLS) eg ession was used o analyze he ends in CS o e ime, weigh ed o
he o al numbe in each en-c oup classi ica ion sys em g oup in ha yea . The Chi-squa e es was
used o analyze he s a is ical signi icance o he di e ences in numbe s o CS be ween he di e en
g oups. In o de o calcula e he isk o CS o women wi h induced e sus spon aneous onse o labo
(g oups 2 and 4 s. g oups 1 and 3), an odds a io (OR) wi h a 95% CI, was calcula ed. The signi icance
le el was se a p<0.05.
3. Resul s
In e ms o he cha ac e is ics o he popula ion, he women’s mean age was 30.7
±
5.6 yea s;
54.4% (8977/16506) we e nullipa ous, and 81.9% (13521/16506) we e na i es o Spain. O he newbo ns,
51.4% (8097/15764) we e males. The mean bi h weigh o he in an s was 3273
±
518 g. In e ms o he
eeding me hod employed a e childbi h, 73.3% (12100/15988) o women chose o b eas eed hei
in an s, wi h nullipa ous women displaying a highe a e in his ega d (78.1% [6792/8687]; p<0.001).
The o al numbe o bi hs o e he nine yea s co e ed by his s udy was 16,506, and he a e o
caesa ean sec ions pe o med o e he pe iod was 19% (Table 2). The e was an inc ease in he CS a e
om 18.4% in 2010 o 20.8% in 2018 by 0.8% (95% CI -0.79-0.86) annually (p<0.001). The e was a
dec ease in he o al numbe o bi hs o e he ime pe iod (mean di e ence be ween 2010/2018:
−
279;
95% CI 265-292; p<0.001).
Table 2.
Dis ibu ion o he s udy’s popula ion acco ding o Robson’s en-g oup classi ica ion sys em,
ela i e and o e all con ibu ion o he CS a e (n=16,506).
Uni e si y Hospi al o la Ribe a Pe iod: Janua y 2010 o Decembe 2018
G oup To al Numbe o CS
in Each G oup
To al Numbe o Women
in Each G oup G oup Size G oup CS
Ra e
Absolu e G oup
Con ibu ion o
O e all CS Ra e
Rela i e Con ibu ion o he
G oup o O e all CS Ra e
1 638 5529 33.5% 11.5% 3.9% 20.4%
2 921 2527 15.3% 36.4% 5.6% 29.4%
2a 768 2374 14.4% 32.4% 4.7% 24.5%
2b 153 153 0.9% 100.0% 0.9% 4.9%
3 338 5283 32.0% 6.4% 2.0% 10.8%
4 402 1578 9.6% 25.5% 2.4% 12.8%
4a 290 1466 8.9% 19.8% 1.8% 9.3%
4b 112 112 0.7% 100.0% 0.7% 3.6%
5 23 118 0.7% 19.5% 0.1% 0.7%
6 304 320 1.9% 95.0% 1.8% 9.7%
7 136 158 1.0% 86.1% 0.8% 4.3%
8 133 229 1.4% 82.1% 0.8% 4.2%
9 35 35 0.2% 100.0% 0.2% 1.1%
10 222 729 4.4% 27.7% 1.2% 6.4%
To al 3132 16,506 100.0% 19.0% 19.0% 100.0%
CS =caesa ean sec ion; G oup size (%) =n o women in he g oup/ o al N women deli e ed in he hospi al x 100;
G oup CS a e (%) =n o CS in he g oup/ o al N o women in he g oup x 100; Absolu e con ibu ion (%) =n o CS
in he g oup/ o al N o women deli e ed in he hospi al x 100; Rela i e con ibu ion (%) =n o CS in he g oup/ o al
N o CS in he hospi al x 100.
In . J. En i on. Res. Public Heal h 2020,17, 1575 5 o 12
Table 2p esen s he dis ibu ion o he s udy’s popula ion in he RTGCS and hei ela i e and
o e all con ibu ion o he CS a e. Figu e 2shows he absolu e con ibu ion o each g oup o he
o e all CS a e o e ime.
In . J. En i on. Res. Public Heal h 2020, 17, 1575 5 o 13
Table 2. Dis ibu ion o he s udy’s popula ion acco ding o Robson’s en-g oup classi ica ion sys em,
ela i e and o e all con ibu ion o he CS a e (n = 16,506).
Uni e si y Hospi al o la Ribe a Pe iod: Janua y 2010 o Decembe 2018
G oup
To al
Numbe o
CS in Each
G oup
To al
Numbe o
Women in
Each G oup
G oup
Size
G oup CS
Ra e
Absolu e
G oup
Con ibu ion o
O e all CS Ra e
Rela i e
Con ibu ion o
he G oup o
O e all CS Ra e
1 638 5529 33.5% 11.5% 3.9% 20.4%
2 921 2527 15.3% 36.4% 5.6% 29.4%
2a 768 2374 14.4% 32.4% 4.7% 24.5%
2b 153 153 0.9% 100.0% 0.9% 4.9%
3 338 5283 32.0% 6.4% 2.0% 10.8%
4 402 1578 9.6% 25.5% 2.4% 12.8%
4a 290 1466 8.9% 19.8% 1.8% 9.3%
4b 112 112 0.7% 100.0% 0.7% 3.6%
5 23 118 0.7% 19.5% 0.1% 0.7%
6 304 320 1.9% 95.0% 1.8% 9.7%
7 136 158 1.0% 86.1% 0.8% 4.3%
8 133 229 1.4% 82.1% 0.8% 4.2%
9 35 35 0.2% 100.0% 0.2% 1.1%
10 222 729 4.4% 27.7% 1.2% 6.4%
To al 3132 16,506 100.0% 19.0% 19.0% 100.0%
CS = caesa ean sec ion; G oup size (%) = n o women in he g oup/ o al N women deli e ed in he
hospi al x 100; G oup CS a e (%) = n o CS in he g oup/ o al N o women in he g oup x 100; Absolu e
con ibu ion (%) = n o CS in he g oup/ o al N o women deli e ed in he hospi al x 100; Rela i e
con ibu ion (%) = n o CS in he g oup/ o al N o CS in he hospi al x 100.
Table 2 p esen s he dis ibu ion o he s udy’s popula ion in he RTGCS and hei ela i e and
o e all con ibu ion o he CS a e. Figu e 2 shows he absolu e con ibu ion o each g oup o he
o e all CS a e o e ime.
Figu e 2. Absolu e con ibu ion o he o e all caesa ean sec ion (CS) a e o each g oup om 2010 o
2018. RTGCS = Robson en-g oup classi ica ion sys em.
Figu e 2.
Absolu e con ibu ion o he o e all caesa ean sec ion (CS) a e o each g oup om 2010 o
2018. RTGCS =Robson en-g oup classi ica ion sys em.
Table 3demons a es he ends in he p opo ions o women in he en g oups o e ime. The da a
show ha nullipa ous women, single on cephalic, e m, classi ied in g oup 1 (spon aneous labo ) and
2 (induced labo o caesa ean be o e labo ) ep esen ed 48.9% o he o al sample, whe eas mul ipa ous
women wi h single on p egnancies who had no unde gone a p e ious CS (g oups 3 and 4) we e 41.6%.
The ela i e con ibu ion o g oup 1 o he global CS a e dec eased, om 22.1% in 2010 o 20.5% in
2018 ( educ ion o 0.56% pe yea ). On he o he hand, i inc eased in g oup 2, going om 23.2% in
2010 o 34.9% in 2018 (an inc ease o 1.50% pe yea ).
Table 3.
T ends in he p opo ions o women in he RTGCS o e ime (weigh ed leas squa es eg ession).
G oup Change in O e all % Pe Yea 95% CI p-Value
1−0.56 −0.58, −0.55 0.001
2 1.50 1.48–1.53 0.001
3−0.72 −0.74, −0.71 0.001
4−0.69 −0.71, −0.66 0.001
5−0.81 −1.13, −0.50 0.001
6 0.12 0.11–0.22 0.031
7−0.19 −0.25, −0.13 0.001
8−0.24 −0.31, −0.17 0.001
9 0.87 0.24–0.97 0.269
10 0.24 0.21–0.27 0.001
CI: con idence in e al.
In . J. En i on. Res. Public Heal h 2020,17, 1575 6 o 12
The mos signi ican con ibu ion o he o e all o al numbe o CS pe o med came om he
women placed in g oup 2. We obse ed ha g oup 1 was 2.2 imes la ge han g oup 2, meaning
ha he numbe o cases o spon aneous ini ia ion o labo was highe han hose o induced labo o
elec i e caesa eans among he nullipa ous. In 2010, he a io be ween g oups 1 and 2 was 2.7:1 and in
2018, i was 1.7:1.
The ela i e con ibu ion o he o e all CS a e o g oups 3 and 4 has educed o e he yea s.
G oup 3 has gone om 14.5% in 2010 o 8.9% in 2018 ( educ ion o 0.72% pe yea ), and g oup 4 has
gone om 16.6% in 2010 o 10.6% in 2018 ( educ ion o 0.69% pe yea ). The compa ison be ween
g oups 3 (mul ipa ous, single on cephalic, e m, spon aneous labo ) and 4 (mul ipa ous, single on
cephalic, e m, induced o caesa ean deli e y be o e labo ) yielded a di e ence o an e en g ea e
magni ude, as he size o g oup 3 was 3.3 imes ha o g oup 4. The a io be ween he sizes o g oups 3
and 4 inc eased om 3.1: 1 in 2010 o 3.4: 1 in 2018.
The ela i e con ibu ion o g oup 5, aginal bi h a e a caesa ean (VBAC) o he global CS a e
dec eased om 0.9% in 2010 o 0.7% in 2018 ( educ ion 0.81% pe yea ).
The ela i e con ibu ion o g oup 6 (all nullipa ous women wi h a single b eech p egnancy) o he
global CS a e inc eased, om 6.0% in 2010 o 11.6% in 2018—an inc ease o 0.12% pe yea . In con as ,
g oup 7 (all mul ipa ous women wi h a single b eech p egnancy including women wi h p e ious
u e ine sca s) educed, om 5.1% in 2010 o 2.7% in 2018—a educ ion o 0.19% pe yea . The a io o
he size o g oup 6 o ha o g oup 7 was 2.0, indica ing ha b eech p esen a ions we e mo e equen
in nullipa ous han in mul ipa ous women. As o e all, he a io be ween g oups 6 and 7 inc eased
om 1.1: 1 in 2010 o 4.4: 1 in 2018.
The ela i e con ibu ion o g oup 8 (all mul iple p egnancies) o he global CS a e has dec eased,
om 5.7% in 2010 o 1.7% in 2018— a educ ion o 0.24% pe yea . The ela i e con ibu ion o g oup
10 o he global CS a e inc eased signi ican ly, om 5.5% in 2010 o 7.5% in 2018—an inc ease o 0.24%
pe yea .
We we e in e es ed in analyzing he di e ences be ween he onse o labo (spon aneous/induced)
and he mode o bi h ( aginal/caesa ean sec ion) in g oups 1 o 4 (Figu e 3). G oup 1 s. 2: 638/4891 CS
om spon aneous onse o labo s. 768/1606 CS om induced onse o labo ; G oup 3 s. 4: 338/4945
CS om spon aneous onse labo s. 290/1176 CS om induced onse o labo . We obse ed ha he
induc ion o labo iples he isk o ha ing a caesa ean sec ion deli e y, compa ed o he onse o
spon aneous labo . The isk was o bo h, in he p imipa ous (g oup 2 s. 1: OR =3.6; 95% CI 3.2–4.1;
p<0.001) as well as in he mul ipa ous g oup (g oup 4 s. 3: OR =3.6; 95% CI 3.0-4.3; p<0.001).
In . J. En i on. Res. Public Heal h 2020, 17, 1575 7 o 13
(g oup 2 s. 1: OR = 3.6; 95% CI 3.2-4.1; p < 0.001) as well as in he mul ipa ous g oup (g oup 4 s. 3:
OR = 3.6; 95% CI 3.0-4.3; p < 0.001).
Figu e 3. Dis ibu ion o ype onse o labo by mode o bi h be ween g oups 1 s. 3, and 2 s. 4 in
he s udy pe iod. Odds a io analyses (* p < 0.001).
We analyzed he indica ion o induc ion o labo in each o he g oups (2a and 4a) and hei
ela ion o he mode o bi h as shown in Table 4. We obse ed ha he i s cause o induc ion was
p olonged p egnancy (PP), wi h a o al caesa ean a e o 21.1% in hese induced labo s, being highe
in g oup 2. In he case o p egnancy-induced hype ension, oligoamnios and p ena al anomalies on
he ca dio ocog aphic (CTG) e al moni o ing, he e was an inc eased a e o CS and he analysis
showed di e ences be ween g oups.
Table 4. Dis ibu ion o indica ion o induc ion o labo in g oups (2a and 4a) and hei ela ion o
he mode o bi h (n = 3840), Chi-squa e analyses.
Induc ion o Labo
Indica ion
G oup (n = 3840)
2a (n = 2374) 4a (n = 1466)
CS
(n = 768)
Vaginal
(n = 1606)
CS
(n = 290)
Vaginal
(n = 1176)
n
%
To al
Row
n % col n % col n % col n % col p-Value
Anomalies on he CTG 193 5.0% 63 8.2% 54 3.4% 23 7.9% 53 4.5% 0.001
P olonged p egnancy 812 21.1% 177 23.0% 341 21.2% 57 19.7% 237 20.2% <0.001
Polyhyd amnios 72 1.9% 17 2.2% 19 1.2% 10 3.4% 26 2.2% 0.088
P egnancy-induced
hype ension 189 4.9% 68 8.8% 66 4.1% 16 5.5% 39 3.3% 0.007
An epa um
hemo hage in he 3 d
imes e
16 0.4% 2 0.3% 12 0.7% 1 0.3% 1 0.1% 0.226
No eco ded 303 7.9% 26 3.4% 133 8.3% 13 4.5% 131 11.1% 0.057
Oligohyd amnios 305 7.9% 69 9.0% 130 8.1% 19 6.6% 87 7.4% 0.002
Fe al pa hology 4 0.1% 3 0.4% 0 0,0% 0 0.0% 1 0.1% 0.046
Ma e nal pa hology 52 1.4% 6 0.8% 20 1.2% 4 1.4% 22 1.9% 0.482
Anhyd amnios 22 0.6% 0 0,0% 15 0.9% 0 0.0% 7 0.6% -
Figu e 3.
Dis ibu ion o ype onse o labo by mode o bi h be ween g oups 1 s. 3, and 2 s. 4 in he
s udy pe iod. Odds a io analyses (* p<0.001).
In . J. En i on. Res. Public Heal h 2020,17, 1575 7 o 12
We analyzed he indica ion o induc ion o labo in each o he g oups (2a and 4a) and hei
ela ion o he mode o bi h as shown in Table 4. We obse ed ha he i s cause o induc ion was
p olonged p egnancy (PP), wi h a o al caesa ean a e o 21.1% in hese induced labo s, being highe in
g oup 2. In he case o p egnancy-induced hype ension, oligoamnios and p ena al anomalies on he
ca dio ocog aphic (CTG) e al moni o ing, he e was an inc eased a e o CS and he analysis showed
di e ences be ween g oups.
Table 4.
Dis ibu ion o indica ion o induc ion o labo in g oups (2a and 4a) and hei ela ion o he
mode o bi h (n=3840), Chi-squa e analyses.
Induc ion o
Labo Indica ion
G oup (n=3840)
2a (n =2374) 4a (n =1466)
CS (n =768) Vaginal (n =1606) CS (n =290) Vaginal (n =1176)
n % To al Row n % col n % col n % col n % col p-Value
Anomalies on he CTG 193 5.0% 63 8.2% 54 3.4% 23 7.9% 53 4.5% 0.001
P olonged p egnancy 812 21.1% 177 23.0% 341 21.2% 57 19.7% 237 20.2%
<0.001
Polyhyd amnios 72 1.9% 17 2.2% 19 1.2% 10 3.4% 26 2.2% 0.088
P egnancy-induced
hype ension 189 4.9% 68 8.8% 66 4.1% 16 5.5% 39 3.3% 0.007
An epa um hemo hage in
he 3 d imes e 16 0.4% 2 0.3% 12 0.7% 1 0.3% 1 0.1% 0.226
No eco ded 303 7.9% 26 3.4% 133 8.3% 13 4.5% 131 11.1% 0.057
Oligohyd amnios 305 7.9% 69 9.0% 130 8.1% 19 6.6% 87 7.4% 0.002
Fe al pa hology 4 0.1% 3 0.4% 0 0,0% 0 0.0% 1 0.1% 0.046
Ma e nal pa hology 52 1.4% 6 0.8% 20 1.2% 4 1.4% 22 1.9% 0.482
Anhyd amnios 22 0.6% 0 0,0% 15 0.9% 0 0.0% 7 0.6% -
Fa o able ce ix 145 3.8% 14 1.8% 57 3.5% 8 2.8% 66 5.6% 0.135
Small o ges a ional age 113 2.9% 21 2.7% 59 3.7% 7 2.4% 26 2.2% 0.573
La en phase 14 0.4% 3 0.4% 5 0.3% 1 0.3% 5 0.4% 0.393
PROM no desc ibed 355 9.2% 55 7.2% 164 10.2% 28 9.7% 108 9.2% 0.327
PROM <12H 14 0.4% 2 0.3% 6 0.4% 0 0.0% 6 0.5% 0.186
PROM >12H <18H 127 3.3% 23 3.0% 46 2.9% 8 2.8% 50 4.3% 0.011
PROM >18H <24H 131 3.4% 20 2.6% 62 3.9% 9 3.1% 40 3.4% 0.422
PROM >24H 390 10.2% 83 10.8% 178 11.1% 31 10.7% 98 8.3% 0.112
Meconium s ained liquo 272 7.1% 48 6.3% 110 6.8% 24 8.3% 90 7.7% 0.085
Suspec ed mac osomia 62 1.6% 10 1.3% 22 1.4% 7 2.4% 23 2.0% 0.485
In au e ine g ow h es ic ion
153 4.0% 34 4.4% 69 4.3% 15 5.2% 35 3.0% 0.708
Ges a ional diabe es 79 2.1% 21 2.7% 30 1.9% 7 2.4% 21 1.8% 0.150
Abno mal dopple s 17 0.4% 3 0.4% 8 0.5% 2 0.7% 4 0.3% 0.793
CS: caesa ean sec ion; CTG: ca dio ocog aphic e al moni o ing; PROM: p olonged up u e o memb anes.
4. Discussion
The p esen s udy includes 16,506 bi hs ha we e a ended a he Ribe a Hospi al du ing he
nine yea s o he s udy pe iod. When s udying he e olu ion o he ac i i y du ing his pe iod o
ime, we obse ed an annual educ ion o a ended bi hs. By con as , he e is an annual inc ease
in he global CS a e, which has mean an inc ease. The da a show ha he e has been a clea end
owa ds inc eased use o CS o e his pe iod, a inding ha echoes hose o o he s udies conduc ed
in Spain [
8
,
14
] and is aligned wi h wo ldwide ends, al hough he a e eco ded is lowe han he
Spanish na ional a e age and ha o o he Eu opean coun ies [
13
,
16
]. The common o e use o CSs is
a signi ican public heal h conce n, and o conside able deba e, due o po en ial ma e nal and pe ina al
isks ha aise heal h ca e cos s, childbi h admissions, and inequi y in he access o ma e ni y heal h
ca e [17,18].
Se e al p e ious s udies documen a signi ican associa ion be ween ad anced ma e nal age
(>35 yea s) and an inc eased likelihood o CS bi h [
19
,
20
]. This associa ion may be in e p e ed as a
esul o a changing social en i onmen , bu a common explana ion is he p e-p egnancy mo bidi ies
associa ed in hese cases [
21
]. Howe e , as no ed in Table 4, only a ew women ha cons i u e ou
s udy p esen ed como bidi y and, none o hem had he age epo ed, as was no equi ed o he
RTGCS. F om ou da a, hen, we would no be able o p o ide a hypo hesis o he ela ion be ween
ma e nal age and he isk o a CS bi h.
The nullipa ous popula ion included in g oups 1 and 2 (nullipa ous, single on cephalic, e m),
was he mos signi ican con ibu o o he o e all CS a e. This inc ease is consis en wi h p e ious
s udies and p obably shows a link o nega i e consequences in women’s heal h in high-income
In . J. En i on. Res. Public Heal h 2020,17, 1575 8 o 12
coun ies [
3
,
22
–
24
]. The ela i e con ibu ion o g oup 1 (spon aneous labo ) o he o e all CS a e
dec eased signi ican ly o e he s udy pe iod, in line wi h o he s udies [
25
]. G oup 2 (induced labo )
makes he g ea es absolu e con ibu ion o he o e all CS a e (4.7% o e ime pe iod), and his is
as pe p e iously published [
26
]. The CS a e o his g oup inc eased signi ican ly o e he s udy
pe iod om 23.2% in 2010 o 34.9% in 2018. These a es o CS a e simila o hose ha ha e been
p e iously epo ed in s udies examining CS a es in Eu opean coun ies using he RTGCS [
22
,
27
].
P e ious epo s ha e desc ibed ha a a io o less han 2:1 be ween he sizes o g oups 1 and 2 may
e lec a high incidence o induc ion and CS be o e labo [
11
]. In 2010, his a io was 2.7:1 and in 2018,
1.7:1. Fu he mo e, du ing he analyzed pe iod, he CS a e inc eased in g oup 2, he eby con ibu ing
signi ican ly o he o e all inc eased CS a e.
The ela i e con ibu ion o he o e all CS a e om g oups 3 and 4 (mul ipa ous, single on
cephalic, e m) has been educed o e he yea s, as obse ed in o he s udies [
27
]. E en hough he
ela i e con ibu ion o g oup 4a (induced mul ipa ous women) o he global CS a e has also dec eased
signi ican ly, i anks as he hi d g oup in e ms o ela i e con ibu ion o he global CS a e in he
s udy. The g oup sizes o g oups 3 and 4 has inc eased, om 3.1: 1 in 2010 o 3.4: 1 in 2018, and his
migh explain he dec ease in he numbe o induc ions in mul ipa ous women. In addi ion, he e
was an inc ease in he numbe o mul ipa ous women wi h spon aneous onse o labo , being able o
explain he dec ease in he numbe o caesa ean sec ions in g oup 4a du ing he s udy.
Once he main con ibu o s o CS a es a e iden i ied, he nex s eps should be ocusing on
po en ial in e en ions o p e en he u he CS ise. The single mos common indica ion o induc ion
in g oups 2a and 4a was PP and, oge he wi h all ypes o PROM excep meconium-s ained liquo ,
hey ep esen almos hal o all indica ions o induc ion o labo . We also no iced ha , in 16.3% o
he medical eco ds, he cause o an induc ion was no s a ed. In addi ion, in ou esul s and as pe
o he s udies [
28
], we obse ed ha induc ion o labo , bo h in nullipa ous and mul ipa ous women,
inc eases he isk o ha ing a caesa ean sec ion. Un il he 2018 elease o a la ge ial ega ding labo
induc ion e sus expec an managemen [
29
], e idence sugges ed ha induc ion o labo wi hou
medical indica ion was associa ed wi h an inc eased a e o caesa ean bi h [
17
]. In o de o educe he
numbe o unnecessa y caesa ean sec ions, i is e y ele an o assess he medical need o induc ion
o labo app op ia ely and documen his p omp ly [24].
In con as wi h o he s udies, we obse e ha he con ibu ion o g oup 5 (women wi h single on
cephalic ull- e m p egnancy, who ha e unde gone a leas one caesa ean sec ion) o he o e all CS
a e was smalle han in o he coun ies like F ance [
23
], UK [
30
], and Canada [
31
], and has been
dec easing du ing he s udy pe iod. Howe e , i was g ea e han I eland [
27
], No way, o Sweden [
30
].
Fu he mo e, ou hospi al has adop ed new guidelines o clinical p ac ice ha ecommend o e ing o
women, who mee op imal clinical condi ions wi h a single on p egnancy o cephalic p esen a ion
a 37 +0 weeks o beyond and who ha e had a single p e ious lowe segmen caesa ean deli e y,
he op ion o ha ing a aginal bi h [
32
]. This new policy migh ha e con ibu ed o a signi ican
dec ease in he a es o caesa ean sec ions among he membe s o his g oup. Fu he mo e, signi ican
di e ences be ween coun ies in VBAC a es may sugges di e en obs e ical ca e p ac ices, some o
hem acili a ing he inc ease on VBAC a es.
Las ly, g oups 8 (mul iple p egnancies) and 10 (p ema u e bi hs) ha e an expec ed con ibu ion
o he gene al CS a e simila o ha epo ed by Robson and o he au ho s [4,11,23,31,33,34].
The e is a need o analyze he possible causes o he global s eady g ow h ha has been obse ed in
he o e all a e o caesa ean sec ions. To his end, i is impo an o seek ou classi ica ion sys ems ha
will allow us o make compa isons be ween di e en heal h ca e sys ems [
1
,
35
]. An ea lie sys ema ic
e iew compa ing di e en classi ica ion me hods concluded ha he Robson classi ica ion is op imal
o moni o ing CS [
1
], and he WHO has ecommended adop ing he Robson classi ica ion as he
global s anda d ool o moni o ing CS [
4
]. The applica ion o he Robson model is a c i ical s ep in
he e o s o op imize he use o hese p ocedu es, as i helps iden i y, analyze, and shed ligh on
how hese in e en ions a e employed among speci ic, ele an g oups a a gi en ins i u ion. I is
In . J. En i on. Res. Public Heal h 2020,17, 1575 9 o 12
documen ed ha he RTGCS is a aluable clinical me hod ha allows s anda dized compa a ions o
da a ac oss coun ies and can be used as a common s a ing poin o audi induc ion o labo and
caesa ean deli e ies ou inely [
13
,
22
,
36
]. Fu he mo e, he use o he classi ica ion sys em applied
in his s udy ac oss Spanish hospi als would help o b ing awa eness on each hospi al pe o mance,
acili a e he compa ison be ween hospi als and egions and align he ma e ni y se ices wi h he
cu en e idence and e e y hospi al speci ic need. A e his s udy was conduc ed, egula audi s and
eedback using he Robson classi ica ion sys em we e implemen ed in ou hospi al in o de o iden i y
issues wi h exis ing p ac ice o imp o e he o e all quali y o ca e.
I is essen ial o a oid unnecessa y in e en ions in childbea ing women, and a he same ime,
ensu e ha hose in e en ions ha a e necessa y ake place [
37
]. E e y e o mus be made o pe o m
hese p ocedu es on he women ha uly need hem a he han me ely a emp ing o each a gi en
op imal a e [13]. Wi h his pe spec i e in mind, i is e en mo e impo an o apply sui able me hods
o moni o and assess he esul s o hese kinds o in e en ions in o de o iden i y when and whe e
hey a e o e used, mainly when hey a e pe o med on heal hy women who a e no deemed o be a
isk. The ma e ni y eam a he hospi al, including he obs e ic and midwi e y eam [
17
], s udied he e,
conduc s a daily, in-dep h e iew o e e y caesa ean sec ion pe o med on he p e ious day in o de o
assess whe he he clinical indica ions ollowed me he s anda ds se ou in he ins i u ion’s p o ocols
and o p o ide eedback o he heal hca e p o essional in ol ed.
Due o he complexi y o he di e en in e connec ed ac o s ha in luence he ising CS a es,
in e en ions aimed o educe unnecessa y CS ha e only shown mode a e success o da e [
1
].
Any inc eases in obesi y, age, and nullipa i y among popula ions o women a e no enough o
explain inc eases. Add essing he non-medical easons ha d i e caesa ean sec ions, he e o e, is key
o educing inapp op ia e use [
38
]. In acco dance o Vogel e al. [
22
], ac o s associa ed wi h highe
a es o aginal bi hs may include i m policies on CS due o ma e nal eques , cul u al o social
p essu e, di e ences in he legal amewo k o medical li iga ion, and s a egies a o ing home bi hs,
midwi e y-led con inui y models o ca e and app oach o bi h [
39
,
40
]. High-quali y esea ch is needed
in he u u e o e alua e mul icomponen and locally ailo ed in e en ions add essing women’s and
heal h p o essionals’ demands as well as he heal h sys em when a emp ing o design and implemen
in e en ions aiming a educing he numbe o unnecessa y CS [41].
S eng hs and Limi a ions
The s eng hs o he s udy include he ac ha ew s udies in Spain ha e analyzed he caesa ean
a e in a single acili y. Mo eo e , he sample was collec ed igo ously, and a sample size ha was
la ge and su icien o he es ima ions made. I , he e o e, p o ides a aluable addi ion o he exis ing
e idence as i p o ides a success ul applica ion o he Robson classi ica ion o analyze he CS a e in
a se ing like a e ia y hospi al and he esul s could be compa ed wi h o he hospi als o egions.
Besides, he esul s ob ained using he Robson classi ica ion me hod con i m he quali y o he da a
collec ed unde he guidelines se ou by he me hod’s au ho o his pu pose.
Among he limi a ions o his s udy is he possible exis ence o eco ding e o s in medical eco ds.
Any e o s ha we e de ec ed we e analyzed by he esea ch eam and ecoded o e lec he da a on
he obs e ic p ocess collec ed in he medical eco d.
5. Conclusions
In ou s udy, he main con ibu o s o he o e all CSs pe o med came om Robson g oups 1, 2,
and 4. E o s o educe he o e all CS a e mus ocus on educing he ini ial CS a e (g oups 1 and
2). Conduc ing a e iew o he indica ions o inducing labo migh be one o he keys o achie ing a
dec ease in he numbe o caesa ean sec ions pe o med a his ins i u ion. The wo ldwide inc ease in
he a e o caesa ean sec ion o e he pas ew decades has made e iden he need o o mula e and
apply a classi ica ion sys em (such as he 10-g oup Robson me hod) ha makes possible a compa ison
o he caesa ean a es a di e en hospi als. Such a sys em can be used o iden i y he g oups displaying
