The analysis of Caesarean Section Rate based on 10 groups Robson’s Classification

Caesarean Section use is growing at a progressive rate globally ,accounting for 21% births world wide in 2015 from 12% in 2000 [1]. According to recommendation for proper prenatal and births care, from a Joint Conference an Appropriate Technology for Birth ,organized by World Health Organization in 1985, there is no justifi cation in any specifi c geographic region to have more than 10-15 % Caesarean Section births [2]. This rising rate is a crucial public health problem ,thus causing debatable questions due to the potential risks both maternal and perinatal. Additionally cost issues and accessibility have Abstract

promptly become concern. Statistically across the US overall CS rate was 32% in 2017 [3] compared to approximately 20% in 1996, in UK CS deliveries have increased 19.7% of birth in 2000 to 26.2% in 2015 [1]. According to Lancet in at least 15 countries the CS rate exceeds 40%, including Brazil, 55.5% Turkey [4] and Egypt 53.1% [5]. Kosovo , a country with the same ethical traits as Albanian is experiencing a swift growth in CS rate. this trend, different authors have created and proposed a consistent and standardized classifi cation known as Robson Classifi cation. Many countries use this randomly in their study ,while other like Albania have not implanted yet. According to WHO the Robson's Classifi cation is for "all women" who delivered at a specifi c setting and not only for the women who delivered by Caesarean Section: It is classifi cation [6]. The groups of the Robson classifi cation include variables: Parity, Previous Caesarean Section, Onset of labor ,Number of foetus, Gestational age, foetal lie and presentation [7].

Objective
The main objective this paper is to report on an analysis of the CS rate in our hospital: "Koco Gliozheni" using the 10 group Robson Classifi cation and to determine trends on time period from 2016-2017.

Materials and methods
This is a retrospective cross -sectional study at the obstetric department of the University Hospital of Obstetric and Gynecology "Koco Gliozheni|"from January 2016 to May 2017. The UHCOG "Koco Gliozheni" is a tertiary University hospital supported by 24 hours obstetrics team, pediatric services ,anaesthetic and neonatal department. This study includes all women who gave births to alive or still born baby of at least 28 weeks gestational age during the above mentioned time period. We have used this cut-off for defi nition of birth ,because the threshold of viability in many low-income countries, as Albania is included as well, is birth weight ≥ 1000 g and gestational age ≥ 28 weeks. The obtain data were maternal age, parity, gestational age, onset of labor, foetus presentation, previous deliveries and previous CS. The data were categorized into 10 groups according to the Robson Classifi cation. System ( Table 1). The groups are as below: Group 1. Nulliparous woman, single cephalic presentation in spontaneous labor. Group 2 is devide in two subgroups: 2a. Nulliparous single cephalic presentation in spontaneous labor, 2b. Nulliparous single cephalic presentation planned caesarean delivery. 3. Multiparous women without uterine scar, single, cephalic, term pregnancy in spontaneous labor. Group 4 is devide in two subgroups: 4a. Multiparous women without uterine scar, cephalic, term, pregnancy in induced labor and 4b. Multiparous women without uterine scar, cephalic term pregnancy, planned caesaren delivery. Group 5. Multiparous with scarred uterus, single, cephalic, term pregnancy. Group 6. Nulliparous single, breech pregnancy. Group 7. Multiparous single breech pregnancy (included women with scarred uterus). Group 8. All women with multiple pregnancy (include them with scarred uterus). Group 9. All women with single or oblique pregnancy (include them with scarred uterus). Group 10. All women with single cephalic preterm pregnancy (include them with scarred uterus).
Those variables needed to be analysed for our study were parity, gestational age, foetal presentation, and previous caesarean section. Statistical analysis and graphics presentation were performed using EXEL 2010 and Microsoft offi ce programs. All missing data cases were exluded from the study.

Results
During our study period from January 2016 to May 2017, 4838 women gave birth at University Hospital of Obstetric-Gynecology "Koco Gliozheni", Tirana.
There were 2388 nulliparous (49.38%) and 2450 multiparous (50.65%). CS was performed in1918 women resulting in an overall CS rate of (39.63%). The number of CS performed to all nulliparous and multiparous during this period of time was 1005(52.5%) and 911(47.5%) respectively. The rate of elective CS was 57.7% while that emergency CS was 42.3%, (Figure 2). We attempted to categorize CS according to Robson Classifi cation and rates of each group were demonstrated separately ( Table  2). The largest contributors to the overall CS rate were women with previous CS (group 5,multiparous with scarred uterus) 12.45%. CS rate within this group was 90.6% (602 out of 664 women). 456 out of 664 women (68.67%),had performed a CS prior to the onset labor (elective CS). 148 (31.33%) of women of this group ,had attempted a VBAC( vaginal birth after Cesarean Section). A signifi cant number of these multiparous, with at least one previous vaginal birth.
The second highest contributors were women included in group 1 (singletons nulliparous, cephalic presentation, at term, spontaneous onset of labor ) , with an overall CS rate 8.9% and with relative percentage of 22.5%.  The group 2 (nulliparous with single cephalic, full term pregnancy, included labor or pre labor CS) had the third contribution with 6.6% of overall CS rate and a relative contribution of only 16.7%.If we analysis inside the group 2 ,we fi nd that the 2b subgroup (elective caesarean delivery) had a contribute with a 6.3% of overall CSR and with a relative contribution of 16.3%.

Discussion
Over the last decades, there has been a progressive increase in the rate of deliveries by Caesarean Section (CS) in most countries but the drivers for this trend are not completely understood [8]. Health Organization (WHO) conducted a systematic review that identifi ed 27 different systems to classify CS. These classifi cations looked at "who" (womanbased), "why" (indication-based), "when" (urgency-based), as well as "where", "how" and "by whom" a CS was performed [9]. This review concluded that women-based classifi cations in general, and the 10-Groups classifi cation in particular [10], were in the best position to fulfi ll current international and local needs. The 10-Groups classifi cation (also known as the "TGCS-Ten Groups Classifi cation System" or the "Robson Classifi cation") was created to prospectively identify welldefi ned, clinically relevant groups of women admitted for delivery and to investigate differences in CS rates within these relatively homogeneous groups of women [10]. WHO expects that the use of the Robson Classifi cation will help health care facilities to: • Identify and analyze the groups of women which contribute most and least to overall CS rates. • Compare practice in these groups of women with other units who have more desirable results and consider changes in practice. • Assess the effectiveness of strategies or interventions targeted at optimizing the use of CS. • Assess the quality of care and of clinical management practices by analyzing outcomes by groups of women. • Assess the quality of the data collected and raise staff awareness about the importance of this data, interpretation and use [11].
Our study reports the data from low income countries like Albania. During the study from January 2016 to May 2017, gave birth 4828 women ,1918(39.63%) out of 4839 performed CS, The rate is higher than developed countries like France (31%, Australia (28%), USA (31.1%) and lower than Iran (40%), Egypt (54%), Turkey (51.9%), South America (42,9%). The main contributor to the overall CS rate were group 5,1,2 . Group 5: (multiparous with prior caesarean section ,singleton ,>37 weeks ) :provides the highest contribution with 31.6% of all CS and with 90.6% CS rate of women in this group much high than Robson's references (50-60%). On further analysis we conclude that 68.67% of women in this group had an elective CS and only 31.33% of women had attempted trail of labor after CS (TOLAC), even thought VABC had a success of 75% [12]. In some studies in low income countries , like India, success of VBAC is as low as 27.4% to 53.6% [13]. But on the other hand ,countries with high socio-economic status (France ,Netherland), reported a higher of CS from group 5( multiparous with prior caesarean section ,singleton ,>37 weeks ) respectively 61% and 47% [14], Some factors that contribute to the decreasing of percentage of VBAC are myth about CS "Once a caesarean always a caesarean", lack of training and malpractice. Uterine  ,is mostly performed for nonmedically indications, the most commen reason is the request of the woman as she refuse to try the vaginal birth also known medical request, due to anxiety fear of pain, and concern of pelvic injury. If we analysis the numbers in the subgroup of elective Caesaren (2b),we conclude that the group contribute with 16.3% of overall CSR and with 54.4% within the group. So it is a considerable percentage ,compares with the contribution of group 2 itself in total.
Group 3-4 (multiparous women at term induced or elective CS) have a relatively low contribution, which reaches all together 7.4%. They are labelled the "low risk group". Groups 6 -10 were smaller groups with an overall size of 11.77%, and with the highest group CSR that reach up to 100% in group 9 (all women with single pregnancy with transverse or oblique lie, including women with previous uterine scar ).This group are presented with a unavoidable obstetric condition (like breech presentation, multiple pregnancy abnormal fetal presentation or premature birth ,several maternal obstetrical conditions) that has been served as medical indication for CS. But on the other hand the contribution to the overall CSR is lower and reaches only 32%. This is similar to the results of other studies of Balkan countries: like Bosnia and Herzegovina [16,17].

Conclusions
In our study, Robson's groups 5.1.2 were identifi ed as the main contributors to the overall Cesarean Section rate at the "Koco Gliozheni" University Hospital, Tirana. It is important to make effort to reduce the overall CSR (reducing CS in group 1 and 2 ) and increasing the attempt of vaginal birth after cesarean section .We believe that this classifi cation can be incorporated successfully in the routine of obstetrical management and implemented in the collection of maternal and perinatal data system to improve the evaluation of Caesarean Section rate.