Jasim & Al-Gharah (2020): Classification using Robson to assess CS 2020 Vol. 23 Issue 7

Use of Robson Classification to Assess Cesarean Section Rate in Al-Samawah City: The Role of Source of Payment for

Dr. Enas Yassen Jasim1, Sama Hisham Al-Gharah2

1Al-Muthanna University, College of Medicine, M.B.Ch.B., F.I.C.M.S., CABGO 2Al Muthanna health directorate Al-hussein teaching hospital, M.B.Ch.B.

Corresponding author: Department of , College of Medicine, Al-Muthanna University, Iraq.

*Corresponding author: [email protected] (Jasim)

Abstract Background: Cesarean section (CS) rates are increasing worldwide but there is some concern with this trend because of potential maternal and perinatal risks. The Robson classification is the standard method to monitor and compare CS rates. Our objective was to analyze CS rates in Al-Samawah city according to source of payment for childbirth (public or private) using the Robson classification. Patients and Methods: This data was collected from Al-Samawah Feminine and children teaching hospital for a period of 1 month from 8/August/2018 to 7/September/2018. We categorized all women into Robson groups and reported the relative size of each Robson group, the CS rate in each group and the absolute and relative contributions made by each to the overall CS rate. Results: The overall CS was 38.8% in which CS deliveries in public sector is more than private sector. The Robson groups with the highest impact on Al-Samawah CS rate in both public and private sectors were group 5( Previous CS, single cephalic, > = 37 weeks) . High-risk women had significantly greater CS rates compared with low-risk women in almost all Robson groups. Conclusion: Public policies should be directed at reducing CS in nulliparous women, particularly by reducing the number of elective CS in these women, and encouraging vaginal birth after cesarean to reduce repeat CS in multiparous women.

Keywords: Cesarean section, Al-Samawah, Robson classifications

How to cite this articleJasim EY, Al-Gharah SH (2020): Use of Robson classification to assess Cesarean section rate in Al-Samawah city: The role of source of payment for childbirth, Ann Trop & Public Health; 23 (7): 1134-1141. DOI: http://doi.org/10.36295/ASRO.2020.23738

Introduction , also known as C-section, or caesarean delivery, is the use of surgery to deliver babies, a caesarean section is often necessary when a vaginal delivery would put the mother or baby at risk; this may include obstructed labor, twin , high blood pressure in the mother, , or problems with the placenta or umbilical cord1. A caesarean delivery may be performed based upon the shape of the mother pelvis or a history of previous C-section, the World Health Organization recommends that C-section be performed only when medically necessary2. Some C-sections are performed without a medical reason, upon request by someone, usually the mother; a C-section was considered an extreme measure, performed when the mother was already dead or considered to be beyond help3. Absolute indications for recommending delivery by caesarean section are few, almost all indications are relative and there will be circumstances where Caesarean section may be best for one woman but not another, although Caesarean section is becoming increasingly safe and evidence is mounting regarding the risks of labor and vaginal delivery, pregnant women, their midwives and doctors need to understand and appreciate the maternal risks associated with the different modes of delivery4. Confidential Enquiries into Maternal Deaths have enabled the risks associated with different methods of delivery to be analyzed; case fatality rate for all Caesarean sections is five times that for vaginal delivery, although for elective Caesarean section the difference does not reach statistical significance, the management in pregnancy following a Caesarean section should be to assess the available options and to select the appropriate choice for an individual woman4. Patient choice cannot and should not be ignored in decisions 1134

Jasim & Al-Gharah (2020): Classification using Robson to assess CS 2020 Vol. 23 Issue 7 regarding management, and it is important to discuss the risks and benefits of elective Caesarean section as compared to trial of vaginal delivery, a C-section typically takes 45 minutes to an hour, it may be done with a spinal block, where the woman is awake or under general anesthesia, a urinary catheter is used to drain the bladder, and the skin of the abdomen is then cleaned with an antiseptic5. An incision of about 15 cm (6 inches) is then typically made through the mother's lower abdomen. The uterus is then opened with a second incision and the baby delivered, the incisions are then stitched closed, a woman can typically begin breastfeeding as soon as she is awake and out of the operating room, often, several days are required in the hospital to recover sufficiently to return home6. From a maternal perspective, elective Caesarean section avoids labor with its risk of perineal trauma (urinary and fetal problems), the need to undergo emergency Caesarean section, and scar dehiscence/ rupture with subsequent morbidity and mortality6. However, elective Caesarean section carries maternal risks these include intraoperative complication as: Hemorrhage that it may be a consequence of damage to the uterine vessels, or may be incidental as a consequence of uterine atony or placenta praevia, in patients with an anticipated high risk of hemorrhage, e.g. known cases of placenta praevia, blood should be routinely cross matched. There are many manoeuvres to manage hemorrhage; these range from bimanual compression, oxytocin infusion, administration of prostaglandins, conservative surgical procedures, such as uterine compression sutures to the more radical, but lifesaving, hysterectomy7. Caesarean hysterectomy is the most common indication for Caesarean hysterectomy is uncontrollable maternal hemorrhage; life-threatening hemorrhage requiring immediate treatment after 1 in 1000 deliveries7. Placenta praevia the proportion of patients with a placenta praevia increases almost linearly after each previous Caesarean section7. Urinary tract damage in this complication the risk of bladder injury is increased after prolonged labors where the bladder is displaced caudally, after previous Caesarean section where scarring obliterates the vesicouterine space, or where a vertical extension to the uterine incision has occurred. If damage is suspected, then transurethral instillation of methylene blue-coloured saline will help to delineate the defect. When such an injury is observed, repair with 2-0 Vicryl as a single continuous or interrupted layer is appropriate. The urinary catheter should remain in situ for 7–10 days. Damage to the ureters is uncommon as reflection of the bladder displaces them rostrally8. The post-operative complications include the following: Infection and endometritis: Women undergoing Caesarean section have a 5–20-fold greater risk of an infectious complication when compared with a vaginal delivery. Complications include fever, wound infection, endometritis, bacteraemia and urinary tract infection. Labor, its duration and the presence of ruptured membranes appear to be the most important risk factors, with obesity playing a particularly important role in the occurrence of wound infections. The most important source of microorganisms responsible for post-Caesarean section infection is the genital tract, particularly if the membranes are ruptured preoperatively9. Pulmonary emboli and deep vein thrombosis :Deaths from pulmonary embolism remain the leading direct cause of maternal death, and Caesarean section is a major risk factor.The incidence of such complications can undoubtedly be reduced by the peri-operative administration of prophylactic heparin and the prompt initiation of treatment when required9. From a fetal perspective, an elective Caesarean section reduces the risk of scar rupture, but increases the risk of transient tachypnoea/respiratory distress syndrome. There is remarkably little evidence to inform practice with regard to management of previous Caesarean section: there are no randomized trials and much of the data relate to observational studies. Consideration of the risk of scar rupture is probably the most important consideration when determining whether delivery should be by elective Caesarean section or by trial of vaginal delivery. Most published studies do not differentiate between scar dehiscence and rupture, however, analysis of observational and comparative studies indicates that the excess risk of uterine rupture following trial of labor compared with women undergoing repeat elective Caesarean section is considerably lower than 1 per cent; indeed, some studies do not demonstrate any increased risk10. Caesarean section rates continue to be an issue of great concern to many midwives, obstetricians, women, and society as a whole. With an increase in women requesting caesarean sections, the responsibility for the caesarean section rate needs to be re-defined. There is a need to improve the routine information collection on all aspects of childbirth. There is also a need to adopt standard classification systems so that comparisons and improvement of care can take place. Caesarean section rates should no longer be thought of as being too high or too low, but rather whether they are appropriate or not, after taking into consideration all the relevant information. This will require statutory, standardized collection of information. Maternal satisfaction has now 1135

Jasim & Al-Gharah (2020): Classification using Robson to assess CS 2020 Vol. 23 Issue 7 become one of the most significant outcome factors after childbirth and must be taken into consideration when implementing any changes in childbirth. Finally, caesarean section rates must no longer be considered in isolation from other changes taking place in society11. Worries over such increases have led the World Health Organization to advise that Cesarean Section (CS) rates should not be more than 15%,with some evidence that CS rates above 15% are not associated with additional reduction in maternal and neonatal mortality and morbidity. Analyzing CS rates in different countries, including primary vs. repeat CS and potential reasons of these, provide important insights into the solution for reducing the overall CS rate. Recently, the WHO adopted the Robson classification system as a global standard for assessing, monitoring and comparing CS rates. Robson’s system classifies women into 10 groups based on five obstetric characteristics that are routinely documented: parity (nulliparous, multiparous with and without previous CS), onset of labor (spontaneous, induced or prelabor CS), (preterm or term), fetal presentation (cephalic, breech or transverse), and number of fetuses (single or multiple). Compared with other CS classifications, Robson’s system offers many advantages. Its categories are mutually exclusive, totally inclusive and can be applied prospectively. The Robson Ten-Group Classification System to allow critical analysis according to characteristics of pregnancy (Table 1)12. The characteristics used were: Table 1: Robson’ 10-Group Classification12. No. Groups 1 Nulliparous, single cephalic, >37 weeks in spontaneous labor 2 Nulliparous, single cephalic, >37 weeks, induced or CS before labor 3 Multiparous (excluding previous CS), single cephalic, >37 weeks in spontaneous labor 4 Multiparous (excluding previous CS), single cephalic, >37 weeks, induced or CS before labor 5 Previous CS, single cephalic, >37 weeks 6 All nulliparous breeches 7 All multiparous breeches (including previous CS) 8 All multiple (including previous CS) 9 All abnormal lies (including previous CS) 10 All single cephalic, <36 weeks (including previous CS) In this article we classified women into the 10 groups described by Tanaka and Kassam12 and into 12 groups using the subdivision of groups 2 and 4 to discriminate the women with induced labor from those with prelabor CS (Table 1), eventually combined the non-cephalic groups (6, 7 and 9) to provide the analysis. We considered that women had gone into labor if they achieved at least 4 cm of cervical dilatation. Induction of labor was defined as the use of any pharmacological (oxytocin or prostaglandins) or mechanical (Foley balloon) agent in women < 4 cm dilated. The prelabor CS group included all women who had a CS and hadn’t gone into labor neither submitted to labor induction13.

PATIENTS AND METHODS Source of data and subjects This cross sectional study was conducted for a period of 1 month from 8/August/2018 to 7/September/2018 at Al-Samawah Feminine and children teaching hospital based on a sample of 552 women with CS and 869 women with normal vaginal delivery. We categorized all women into Robson groups and reported the relative size of each Robson group, the CS rate in each group and the absolute and relative contributions made by each to the overall CS rate. Also we categorized the women with CS only into public and private and identify the percentage of each of them.

Robson groups and covariables The variables necessary for applying the Robson classification are: number of fetuses (single or multiple); fetal presentation (cephalic, breech or transverse); previous obstetric record (nulliparous or multiparous, with or without uterine scar); onset of labor and delivery (spontaneous, induced or prelabor CS); and gestational age at the time of delivery. We classified women into the 10 groups described by Robson and into 12 groups using

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Jasim & Al-Gharah (2020): Classification using Robson to assess CS 2020 Vol. 23 Issue 7 the subdivision of groups 2 and 4 to discriminate the women with induced labor from those with prelabor CS (Table 3), and eventually combined the non-cephalic groups (6, 7 and 9) to provide the analysis. We considered that women had gone into labor if they achieved at least 4 cm of cervical dilatation. Induction of labor was defined as the use of any pharmacological (oxytocin or prostaglandins) agent in women < 4 cm dilated. The prelabor CS group included all women who had a CS and hadn’t gone into labor neither submitted to . Obstetric characteristics investigated were: “age”(less than 20, 20-34 and more than 34), “parity” (0, 1 or ≥ 2); “number of previous CS” (0, 1, 2, or more); “type of pregnancy” (single, multiple); “induction of labor” (yes/no); and high obstetric risk. High obstetric risk covered the following complications: hypertensive disorders, eclampsia, preexisting diabetes, gestational diabetes, severe chronic diseases, infection at hospital admission for birth (including urinary tract infection and other sever infection such as chorioamnionitis and pneumonia), placental abruption, placenta previa, intrauterine growth restriction and major newborn malformation (including anencephaly, hidrocephaly, spina bifida, gastrosquisis and other abdominal wall defects, cardiac malformations and multiple malformations).

RESULTS The overall CS rate is 38.8%, 67.4% in public sector and 32.6% in private sector. The rate of women aged 20- 34 is 77.4%, 78.5% in public sector and 75% in private sector. The rate of multiparous women is 59.4%, 59.9 in public sector and 58.3 % in private sector. The rate of induction of labor is 2.4%. Women with high obstetric risk are 22.6%, 20.96% in public sector and 26.1% in private sector (Table 2).

Table 2: Characteristics of women by source of payment of birth. total n % public n % private n % Chi square P-value Total 552 372 180

maternal age N % N % N %

<20 33 6 26 6.99 7 3.9 0.07 20-34 427 77.4 292 78.5 135 75

>34 92 16.6 54 14.5 38 21.1

Parity

0 113 20.5 63 16.9 50 27.8 0.003 1 111 20.1 86 23.1 25 13.9

_> 2 328 59.4 223 59.9 105 58.3

Previous caesarean

0 243 44 143 38.4 100 55.6 0.0005 1 125 22.6 96 25.8 29 16.1

_>2 184 33.3 133 35.8 51 28.3

Type of pregnancy

Single 536 97.1 363 97.6 173 96.1 0.33 Multiple 16 2.9 9 2.4 7 3.9

Induction of labor

Yes 13 2.4 13 3.5 0 0.04 No 539 97.6 359 96.5 180 100

High obstetric risk

Yes 125 22.6 78 20.96 47 26.1 0.18 No 427 77.4 294 79.03 133 73.9

Table 3: show distribution of women by robson group. Group 5 account for(45.3%) from all groups, while group 4 (13.6 %) , group 2(11.9%), group 10 (10.3%) , group 7 (8.3%), group1 (4%), group 8 (2.4%), group 6 (2.2%), group 3 (1.3%) and group 9 (0.7%) from CS.

Table 3: Robson classification in birth in Samawah , August, 2018. Robson Description of Number Number Relative CS Absolute Relative group obstetric of of (%) size rate contribution (%) populations cesarean deliveries of (%) in (%) on the contribution deliveries group1 each overall CS on the group2 rate3 overall CS rate4

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1 Nulliparous 22 142 10 15.5 1.55 4 women, single cephalic, > = 37 weeks, in spontaneous labor 2 Nulliparous 66 101 7.11 65.3 4.6 11.9 women, single cephalic, > = 37 weeks, induced or CS before labor 2a Nulliparous 6 101 7.11 5.9 0.42 1.1 women, single cephalic, > = 37 weeks, induced labor 2b Nulliparous 60 0 0 0 4.2 10.9 women, single cephalic, > = 37 weeks, CS before labor 3 Multiparous 7 335 23.6 2.1 0.5 1.3 women (excluding prev. CS), single cephalic, > = 37 weeks, in spontaneous labor 4 Multiparous 75 195 13.7 38.5 5.3 13.6 women without a previous uterine scar, with single cephalic pregnancy, > = 37 weeks, induced or CS before labor 4a Multiparous 3 83 5.8 3.6 0.2 0.5 women without a previous uterine scar, with single cephalic pregnancy, > = 37 weeks, induced labor 4b Multiparous 72 112 7.9 64.3 5.1 13.04 women without a previous uterine scar, with single cephalic pregnancy, > = 37 weeks, CS before labor 5 Previous CS, 250 10 0.7 2500 17.6 45.3 single cephalic, > = 37 weeks 6 All nullipara 12 29 2.04 41.4 0.8 2.2 breeches 7 All multipara 46 21 1.5 219 3.2 8.3 1138

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breeches (including prev. CS) 8 All multiple 13 28 1.97 46.4 0.9 2.4 pregnancies (including prev. CS) 9 All abnormal lies 4 1 0.07 400 0.28 0.7 (including prev. CS) 10 All single 57 7 0.5 814 4.01 10.3 cephalic, <=36 weeks (including prev. CS) Total 552 869 1. (Number of deliveries in the group) / (Total number of deliveries)*100 2. (Number of cesarean deliveries in the group) / (Number of deliveries in the group)*100 3. (Number of cesarean deliveries in the group) / (total number of deliveries)*100 4. (Number of cesarean deliveries in the group) / (total number of cesarean deliveries)*100 Table 4: show compares between source of payment in Relative percentage contribution on the overall CS rate and absolute contribution on the overall CS only as all normal vaginal delivery was done in public sector only so we don't mentioned it. In public sector the proportion of women in group 5 was higher (35% vs. 10.3%), while in private sector the proportion of women in group 10 was higher(5.8% vs. 4.5%).

Table 4: Robson group by source of payment of birth, August, 2018 Description of obstetric Number of cesarean deliveries Number of cesarean deliveries populations public Relative (%) Absolute Private Relative (%) Absolute contribution contribution contribution contribution on the (%) on the on the (%) on the overall CS overall CS overall CS overall CS 1 2 Robson group rate rate rate rate 1 Nulliparous women, 15 2.7 1.1 7 1.3 0.5 single cephalic, > = 37 weeks, in spontaneous labor 2 Nulliparous women, 35 6.3 2.5 31 5.6 2.2 single cephalic, > = 37 weeks, induced or CS before labor 2a Nulliparous women, 6 1.1 0.4 0 0 0 single cephalic, > = 37 weeks, induced labor 2 Nulliparous women, 29 5.2 2.04 31 5.6 2.2 b single cephalic, > = 37 weeks, CS before labor 3 Multiparous women 6 1.1 0.4 1 0.2 0.07 (excluding prev. CS), single cephalic, > = 37 weeks, in spontaneous labor 4 Multiparous women 48 8.7 3.4 27 4.9 2 without a previous uterine scar, with single cephalic pregnancy, > = 37 weeks, induced

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or CS before labor 4a Multiparous women 3 0.5 0.2 0 0 0 without a previous uterine scar, with single cephalic pregnancy, > = 37 weeks, induced labor 4 Multiparous women 45 8.2 3.2 27 4.9 2 b without a previous uterine scar, with single cephalic pregnancy, > = 37 weeks, CS before labor 5 Previous CS, single 193 35 13.6 57 10.3 4 cephalic, > = 37 weeks 6 All nullipara breeches 8 1.4 0.6 4 0.7 0.3 7 All multipara breeches 32 5.8 2.3 14 2.5 0.1 (including prev. CS) 8 All multiple 7 1.3 0.5 6 1.1 0.4 pregnancies (including prev. CS) 9 All abnormal lies 3 0.5 0.2 1 0.2 0.07 (including prev. CS) 10 All single cephalic, 25 4.5 1.8 32 5.8 2.3 <=36 weeks (including prev. CS) 1. (Number of cesarean deliveries in the group) / (total number of cesarean deliveries)*100 2. (Number of cesarean deliveries in the group)/(total number of deliveries)*100

The analysis of CS by robson groups show that CS in public sector is more than private (67.4% in public and 32.6% in private) and most women is classified in group 5(35% in public sector and 10.3% in private sector).

DISCUSSION Numbers of cesarean deliveries was increased worldwide. In this study in Al-Samawah city we found that the percentage of women who undergo CS is 38.8% compared with the percentage of normal vaginal delivery 61.2% .Other main finding is that most women with CS is classified in group 5( Previous CS, single cephalic, > = 37 weeks), group 4(Multiparous women without a previous uterine scar, with single cephalic pregnancy, > = 37 weeks, induced or CS before labor) while only 4 women classified in group 9(All abnormal lies including prev. CS). Also women in public sector 372 and in private sector 180. Women with high risk are 125 and without risk are 427. High-risk women had significantly higher CS rates when compared with low-risk women in almost all Robson groups. In this study we take the information from the patients except in some patients in gestational age we depended on last menstrual period not the last ultrasound. Other women who undergo CS also perform tubal ligation at the same time and most of them without previous history of CS so they classified in group 4.Our study showed that women how delivers in private sector is highly educated. The non-use of labor induction in the private sector was also remarkable. Even in the public sector, the rate of induced deliveries was lower than in countries with low CS rates, such as France and the Netherlands14, 15, 16, 17. In Brazil the overall CS rate was 51.9 %: 42.9 % in the public and 87.9 % in the private sector and almost 80 % of women were from groups 1, 2, 3 and 5, while groups 6, 7, 8 and 9 accounted for only 5 % of deliveries. The single, cephalic, preterm group (group 10) represented almost 10 % of births. Group 2 was the single largest group in the study, comprising 20 % of the whole population. Within this subset of nulliparas at term with a single cephalic infant, approximately 70 % of them were submitted to prelabor CS and nearly 30 % had labor induced. Almost 65 % of all CSs performed in Brazil were from groups 2 and 5. Groups 1, 4 and 10 contributed to 6.8 %, 8.3 % and 9.4 % of the CS, respectively. Recently, a WHO analysis found that CS rate and the absolute contribution of group 5 has increased in recent years. These data show the domino effect of CS use: rising CS rates, especially in nulliparous women, increase the number of women with previous CS, who are more likely to undergo a repeat CS18. 1140

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CONCLUSIONS This is an analysis of CS rates in Al-Samawah by Robson classification using data from the entire city. The Robson classification identifies the contributors to the CS rate, but does not provide insight into the reasons or explanation for the observed differences18. However, this classification helps to identify the target groups that may benefit from implementations or interventions, and guide public policies and investments for reducing CS rates in Al-Samawah. Public policies should be directed at reducing CSs in nulliparous women, particularly by reducing the number of elective CSs in these women. The extended use of labor induction and its appropriate management rather than CS before labor would be an important measure for reducing CS rates.

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