Abstract
Introduction
The number of cesarean sections (CSs) has grown steadily, but the underlying factors driving this increase remain unknown. Data from Medical Birth Registries were retrieved to analyze CS trends in Estonia and Finland during the period 1992–2016.
Material and methods
All births in Estonia (n = 356 063) and Finland (n = 1 437 234) were included. The differences between Estonia and Finland in five‐year time periods for the total CS rate, and rates in Robson 1, 2, and 5 groups (R1, R2, R5) were analyzed by logistic regression. Total CS rates were adjusted for birthweight, parity, previous CS, gestational age, singleton pregnancy, cephalic position, induction, mother's age. R1; R2; R5 rates were adjusted for birthweight and mother's age.
Results
In Estonia, the proportion of CSs increased from 6.5% to 21.0% and in Finland from 15.1% to 16.8% between 1992 and 2016. In 2016, Estonia and Finland remained within the target value with their R1 + 2 (Estonia 18%; Finland 16%) and R5 (Estonia 59%; Finland 42%) values.
Conclusions
Comparing Robson groups in different countries can shed light on divergent CS rates and to improve the quality of perinatal and obstetric care.
Keywords: cesarean section, Estonia, Finland, registry‐based data, Robson criteria
Cesarean section (CS) trends were analyzed in Estonia and Finland from 1992 to 2016. Finland was chosen as a comparator country during the transition period after independence from the former Soviet Union. Today, Finland and Estonia have comparable perinatal outcomes. Still, the difference in CS rates is due mainly to a higher proportion of CSs among singleton‐term pregnancies with a previous CS rate in Estonia.
Abbreviations
- CS
cesarean section
- R1
Robson 1: Nulliparous, single, cephalic, ≥37 weeks, spontaneous labor
- R2
Robson 2: Nulliparous, single cephalic, ≥37 weeks, induced or CS before labor
- R5
Robson 5: Multiparous, previous CS, single cephalic, ≥37 weeks.
- WHO
World Health Organization
Key message.
Cesarean section trends in Estonia and Finland from 1992 to 2016 show that Finland and Estonia have comparable perinatal outcomes, but the cesarean section rate in Estonia surpassed Finland in 2003 and has remained stable since 2007.
1. INTRODUCTION
Over the last 30 years, the number of cesarean sections (CSs) in the world has grown steadily, yet the precise cause is unknown. 1 As early as 1985, the World Health Organization (WHO) stated that the CS rate should be less than 15%. 2 In Europe, the proportion of CSs has increased from 11.2% to 25.0% between 1990 and 2014. 3 The proportion of CSs varies greatly between European countries, with Nordic countries having the lowest rates. In 2015, the median CS rate was 27.0% while the range was 16.1%–56.9%. 4 By 2019, the median CS rate had decreased slightly to 26.0% and the range narrowed slightly (16.4%–53.1%). 5 The Nordic countries have a lower proportion of CSs than the rest of Europe 6 yet even in Finland, the proportion of CSs had risen from 14.5% to 16.4% by 2015. 7 , 8 In 2019, CS rates increased most in Hungary, Poland, Croatia, Ireland, and Scotland; the steepest decline was in Cyprus (56.9% to 53.1%) where CS rates are the highest in Europe. 5 The increase in CS rates and the wide variation by country is likely multifactorial in nature. 1
In 2001, Dr Michael Robson proposed the Ten‐Group Classification System (TGCS), which categorizes the women giving birth according to perinatal outcomes and events in these groups. The classification is for all women, not only for the women who deliver by CS. Robson's system is based on obstetric parameters: parity, previous CS, gestational age, the onset of labor, fetal presentation, and the number of fetuses. 9 The system divides births into 10 groups according to obstetric parameters (WHO Robson Classification: Implementation manual Link 10 ), thus Robson's criteria are well suited for international benchmarking. The CS rates in Nordic countries (Denmark, Finland, Iceland, Norway, and Sweden) are described using Robson's criteria during the period 2000–2011. The main increase in the CS rate was among first‐time mothers, especially those with induced labor and mothers with a previous CS. 6 In 2015, the 27 EU countries plus Iceland, the UK, Norway, and Switzerland were categorized according to 2015 Robson criteria on the basis of Euro‐Peristat data. It was concluded that a high CS rate overall is also associated with elevated CS rates in each of the Robson groups. 8
Estonia and Finland are neighboring countries by the Baltic Sea. In 2022, the population of Finland was 5.55 million. 11 The population of Estonia in 2022 was 1.33 million. 12 The Republic of Estonia was a member of the Soviet Union until it regained its independence in 1991. The Finnish Medical Birth Registry was created in 1987, followed by the Estonian Medical Birth Registry in 1991, with data collection commencing on January 1, 1992. The Finnish Medical Birth Registry predated Estonia's registry and was used as a model, thus the Finnish and Estonian Birth Registers are constructed similarly and are suitable for comparison. 7
The aim of this registry‐based study was to compare CS trends in Estonia and Finland from 1992 to 2016, and in addition among full term singleton deliveries according to Robson 1, Robson 2, and Robson 5 criteria.
2. MATERIAL AND METHODS
All deliveries in Estonia and Finland in the years 1992–2016 were included in this study. The data obtained from the Estonian Medical Birth Registry and Finnish Medical Birth Registry included the following variables: mother's age; gestational age; number of previous deliveries; pregnancy risk factors (eg previous CS); gestational age; mode of delivery (vaginal delivery, vacuum extraction, planned CS, other CS); other operations on delivery (eg induction); analgesia in the delivery (eg epidural/spinal anesthesia); puerperal and postnatal diagnoses (eg the direct posture of the pelvis, other atypical fetal condition); birthweight; and number of children;
2.1. Statistical analyses
From the Finnish Medical Birth Registry, data for 1 481 160 births were extracted, and from the Estonian Medical Birth Registry, data for 356 063 births were extracted.
We analyzed total CS rates and stratified according to Robson 1, Robson 2 and Robson 5 criteria to identify which factor was associated with increased rates. Robson groups are categorized as follows R1: nulliparous, single, cephalic, ≥37 weeks, spontaneous labor; R2: nulliparous, single, cephalic, ≥37 weeks, induced or CS before labor; R5: previous CS, single, cephalic, ≥37 weeks. 9
We analyzed the following descriptive characteristics and obstetrical factors in Estonia and Finland: maternal age; birthweight; parity, nulliparous; CS; gestational age, ≥ 37 weeks; onset of labor, induction; multiparous, previous CS; presentation, cephalic; singleton pregnancy. These figures were divided into five time periods (1992–1996; 1997–2001; 2002–2006; 2007–2011; 2012–2016). A logistic and linear regression model was used to determine time trends. Trends with a p‐value <0.05 were considered statistically significant.
The differences between Estonia and Finland during the five time periods for the total CS rate, R1, R2, and R5, were fit to an adjusted logistic regression model. The dependent variable was CS rate adjusted for birthweight, parity, previous CS, gestational age, singleton pregnancy, cephalic position, induction, and mother's age. The R1; R2; R5 rates were adjusted for birthweight and mother's age. Results are presented by odds ratios (OR) and 95% confidence interval (CI). Again, p‐values less than 0.05 were considered statistically significant. The statistical software used was Stata/IC 14 for Windows. 13
2.2. Ethics statement
The study was approved by the Tallinn Research Ethics Committee of the National Institute for Health Development (decision no. 2767A) on May 30, 2019. The Estonian National Institute for Health Development granted permission to use the Estonian anonymized registry data. THL Finnish Institute for Health and Welfare granted permission (no. THL/712/5.05.00/2018) on April 10, 2018 to use the Finnish anonymized registry data.
3. RESULTS
Trends in the total number of births in Estonia and Finland were similar (Table 1). The number of deliveries in both countries was highest during 1992–1996 and 2007–2011. The average age of mothers at birth rose steadily in both countries, reaching a mean of 30 years. The average birthweight of children trended higher in Estonia but decreased in Finland. In Estonia, the proportion of nulliparous decreased from 49% to 42% and is now similar to Finland's fairly stable rates fluctuating between 39%–42%. The proportion of elective CSs increased in Estonia until 2011 and then decreased slightly; in Finland, the share of elective CSs increased until 2006, after which it started to decrease slowly. The non‐elective CS rates have been steadily rising in both countries. Full‐term pregnancies form about 93% of all births in Estonia and about 94% in Finland. The proportion of induced labor has increased in both countries. In Estonia, 14% of all births were induced in the period 2012–2016, compared with 23% in Finland. In both countries, the proportion of women with a history of a previous CS has increased. In Estonia, it rose from 2% to 10% while in Finland the previous CS rate remained stable at 9%–11%. The proportion of cephalic presentation in both Estonia (95%–96%) and Finland (92%–94%) was quite stable. In Estonia, there was no statistically significant difference between cephalic presentation over time periods; in Finland, however, such a significant difference existed. Single births accounted for 96%–98% of all births in both countries.
TABLE 1.
Descriptive characteristics of births, Estonia and Finland, 1992–2016.
| Births, n | Maternal age mean/(SD) | Birthweight mean/(SD) | Parity, Nulli‐ parous, n (%) | Non‐elective cesarean section, n (%) | Elective cesarean section, n (%) | Gestational age, ≥37 weeks, n (%) | Onset of labor, Induced, n (%) | Multiparous, previous CS, n (%) | Presentation, cephalic, n (%) | Singleton pregnancy, n (%) | |
|---|---|---|---|---|---|---|---|---|---|---|---|
| Estonia | |||||||||||
| 1992–96 | 74 296 | 25.1 (5.5) | 3451 (580.5) | 36 909 (49.7) | 3652 (4.9) | 2603 (3.5) | 69 515 (93.6) | 4021 (5.4) | 1583 (2.1) | 71 136 (95.7) | 72 942 (98.2) |
| 1997–01 | 63 076 | 26.1 (5.6) | 3486 (590.4) | 31 042 (49.2) | 5723 (9.1) | 3202 (5.1) | 59 192 (93.8) | 4475 (7.1) | 2029 (3.2) | 60 371 (95.7) | 61 771 (97.9) |
| 2002–06 | 69 525 | 27.3 (5.7) | 3502 (595.0) | 33 994 (48.9) | 7965 (11.5) | 4613 (6.6) | 65 176 (93.7) | 6040 (8.7) | 3575 (5.1) | 66 556 (95.7) | 67 785 (97.5) |
| 2007–11 | 78 778 | 28.4 (5.7) | 3507 (593.8) | 35 781 (45.4) | 10 546 (13.4) | 6147 (7.8) | 73 824 (93.7) | 7926 (10.1) | 6386 (8.1) | 75 178 (95.4) | 76 349 (96.9) |
| 2012–16 | 70 388 | 29.5 (5.5) | 3506 (581.2) | 29 745 (42.3) | 9236 (13.1) | 5115 (7.3) | 65 995 (93.8) | 9927 (14.1) | 7406 (10.5) | 67 589 (96.0) | 68 146 (96.8) |
| Trend p‐value | <0.001 | <0.001 | <0.001 | <0.001 | <0.001 | <0.001 | 0.924 | <0.001 | <0.001 | 0.171 | <0.001 |
| Missing data | 0 | 0 | 147 | 0 | 0 | 0 | 160 | 0 | 0 | 0 | 0 |
| Finland | |||||||||||
| 1992–96 | 320 900 | 28.9 (5.1) | 3539 (590.0) | 126 774 (39.5) | 25 621 (8.0) | 25 151 (7.8) | 302 353 (94.2) | 48 018 (14.9) | 31 280 (9.7) | 304 335 (94.8) | 311 493 (97.0) |
| 1997–01 | 286 739 | 29.4 (5.4) | 3516 (589.3) | 115 769 (40.3) | 25 107 (8.8) | 22 342 (7.8) | 269 423 (94.0) | 43 147 (15.0) | 28 974 (10.1) | 267 920 (93.4) | 277 471 (96.8) |
| 2002–06 | 286 808 | 29.5 (5.5) | 3509 (580.1) | 120 753 (42.1) | 27 066 (9.4) | 21 915 (7.6) | 270 185 (94.2) | 47 671 (16.6) | 29 963 (10.4) | 265 796 (92.7) | 278 210 (97.0) |
| 2007–11 | 301 153 | 29.6 (5.3) | 3489 (572.3) | 126 427 (42.0) | 30 981 (10.3) | 20 003 (6.6) | 283 894 (94.3) | 54 807 (18.2) | 32 206 (10.7) | 281 117 (93.3) | 292 252 (97.0) |
| 2012–16 | 285 560 | 30.0 (5.3) | 3493 (563.0) | 117 788 (41.2) | 29 456 (10.3) | 18 520 (6.5) | 268 987 (92.2) | 65 758 (23.0) | 31 707 (11.1) | 265 730 (93.1) | 277 808 (97.2) |
| Trend p‐value | <0.001 | <0.001 | <0.001 | <0.001 | <0.001 | <0.001 | 0.654 | <0.001 | <0.001 | <0.001 | <0.001 |
| Missing data | 0 | 2 | 2968 | 2202 | 0 | 0 | 5374 | 0 | 0 | 0 | 0 |
Figure 1 shows that in 1992, 6.5% of all births in Estonia and 15.1% of births in Finland were by CS. In Estonia, CS rates rose sharply between 1992 and 2005 (~8% per year) and remained stable during the period from 2006 to 2016 then dropped slightly (−0.05% per year). Until 2002, there were fewer CSs in Estonia than in Finland. Since 2003, however, the total number of CSs in Estonia has exceeded that of Finland. In Finland, CS rates also rose between 1992 and 2002, but less steeply (~1% per year) and from 2003 to 2016 (0.18% per year). In Finland, the total percentage of CSs between 1992 and 2016 has been quite stable, remaining between 15% and 17%. In Estonia, the total percentage of CSs has remained stable between 20% and 21% since 2007.
FIGURE 1.
Time trends of total cesarean section (CS) rates in Estonia and Finland, 1992–2016.
Figure 2 shows that the starting points in Estonia and Finland for Robson 1 (nulliparous, single cephalic, ≥37 weeks, spontaneous labor) and Robson 2 (nulliparous, single cephalic, ≥37 weeks, induced or CS before labor) in 1992 were different. Estonia's starting point was significantly lower than Finland. Since 1998, R1 in Estonia reached the same level as Finland and increased since then. In Estonia, the proportion of R2 increased from 32% in 1992 but decreased again, returning to nearly the same level by 2016. In Finland, R2 decreased from 39% to 30%. The Robson 5 proportions (previous CS, single, cephalic, ≥37 weeks) have remained different throughout the study period. In Estonia, R5 fluctuated between 70% and 80% for a long time but since 2010 this proportion has started to decrease sharply, decreasing to less than 59% by 2016. In contrast, the R5 proportion in Finland has generally remained less than 50%.
FIGURE 2.
Time trends of cesarean section (CS) rates in groups R1, R2 and R5 in Estonia and Finland, 1992–2016.
Table 2 shows that the total incidence of CS (adjusted by birthweight, parity, previous CS, gestational age, singleton pregnancy, cephalic position, induction, and mother's age) in 1992–1996 for Estonia compared to Finland was OR 0.73 (95% CI: 0.71–0.76). After 1996, the odds of CS were higher in Estonia than Finland, increasing over all five‐year periods except in 2012–2016. In the Robson 1 group, the odds of CS (adjusted by birthweight and mother's age) in Estonia in 1992–1996 was 0.70 compared to Finland (95% CI: 0.65–0.74). In 1997–2001 the odds of R1 in Estonia surpassed Finland and increased further through the period 2001–2007, then remained relatively constant. In the Robson 2 group, the odds of CS (adjusted by birthweight and mother's age) in Estonia during the period 1992–1996 was 1.06 (95% CI: 0.97–1.16) statistically indistinguishable from Finland. The CS rate increased until 2006 then decreased slightly yet remained higher than in Finland. In the R5 group (adjusted by birthweight and mother's age), the odds of CS were more than three times higher in Estonia during the years 1992–2006. After 2007, this disparity narrowed to 2.01 during the period 2012–2016 (95% CI: 1.90–2.13), after adjusting for birthweight and the mother's age. For all time periods, the R1 and R5 differences were statistically significant.
TABLE 2.
Probability of a CS in Estonia compared to Finland in 1992–1996 (adjusted by birthweight, parity, previous CS, gestational age, singleton pregnancy, cephalic position, induction, mother‘s age).
| Finland | Estonia adjusted OR | |||||
|---|---|---|---|---|---|---|
| 1992–1996 95% Cl | 1997–2001 95% Cl | 2002–2006 95% Cl | 2007–2011 95% Cl | 2012–2016 95% Cl | ||
| Total CS a | 1 | 0.73 | 1.35 | 1.65 | 1.75 | 1.52 |
| (0.71–0.76)* | (1.31–1.39)* | (1.61–1.69)* | (1.71–1.79)* | (1.48–1.55)* | ||
| R1 b | 1 | 0.70 | 1.27 | 1.53 | 1.52 | 1.52 |
| (0.65–0.74)* | (1.21–1.34)* | (1.46–1.61)* | (1.46–1.59)* | (1.45–1.59)* | ||
| R2 b | 1 | 1.06 | 1.50 | 1.66 | 1.49 | 1.26 |
| (0.97–1.16) | (1.38–1.63)* | (1.54–1.79)* | (1.39–1.59)* | (1.18–1.35)* | ||
| R5 b | 1 | 3.04 | 3.06 | 3.31 | 2.97 | 2.01 |
| (2.68–3.43)* | (2.74–3.41)* | (2.78–3.16)* | (2.78–3.16)* | (1.90–2.13)* | ||
Abbreviations: CS, cesarean section; OR, odds ratio; R1, nulliparous, single, cephalic, ≥37 weeks, spontaneous labor; R2, nulliparous, single cephalic, ≥37 weeks, induced or CS before labor; R5, multiparous, previous CS, single cephalic, ≥37 weeks.
Total CS adjusted by birthweight, parity, previous CS, gestational age, singleton pregnancy, cephalic position, induction, mother‘s age.
R1; R2; R5 adjusted by birthweight; mother‘s age.
p < 0.001.
4. DISCUSSION
During the years 1940–1991, when Estonia was part of the Soviet Union, the country experienced a period of profound stagnation during which time there was a dramatic decline in population health. Reforms in health care and social systems have since significantly changed the populations. 14 The Health Insurance Act was established in Estonia in 1992 and in 1994 the Central Health Insurance Fund was created. In 2001, solidarity‐based, the Estonian Health Insurance Fund was enacted by law and remains a social welfare policy. 15 These major changes to the Estonian healthcare system have dramatically improved health outcomes. For example, in 1996 the Estonian perinatal mortality rates were more than double that of Finland (13.0/1000 vs. 5.7/1000, respectively). 7 By 2016 the rates were similar (2.3/1000 vs. 1.9/1000, respectively) 16 Within 25 years, Estonia became one the safest countries in the world for giving birth.
Subsequent to these public health policy changes and government funding, improvements in access to perinatal and obstetric care in Estonia have led to dramatic decreases in perinatal mortality. At‐risk pregnant women are referred to a higher‐stage medical facility to give birth. 7 The Estonian Gynecologists' Society regularly reviews scientific developments and issues new practice guidelines. Adherence to these guidelines should counterbalance the potential adverse effects of medical trends in the maternity population as well as other economic and social pressures regarding delivery choices. 17
In 2013, in cooperation with the Estonian Health Insurance Fund and the University of Tartu, the advisory council for treatment quality indicators was formed. The council established principles for selecting indicators characterizing the quality of treatment. These indicators are proposed by professional societies and evaluated by the council according to its principles. This process of indicator selection has generated five main obstetric care indicators in Estonia, one of which is the rate of CSs in primipara with singleton delivery when the fetus is in the cephalic position (Robson 1 + 2). The second is the rate of CSs in multiparous in the case of singleton births in which at least one delivery has ended by CS and whose fetus is in the cephalic position (Robson 5). Indicators are used to monitor treatment quality as well as resource utilization to ensure optimal functioning of the healthcare system. 18 In 1992, the Estonian Medical Birth Registry was created to track outcomes of all pregnancies, deliveries, and newborns. 7 In Finland and Estonia, data collection and registration, data analysis, and research also play an essential role in guiding policy so the indicators rates stay more stable. 19 , 20
The strength of the study is the long study period (25 years) and the use of a population‐based registry. Estonian and Finnish Medical Birth Registers are similar and therefore the data are easily comparable. The Birth Registers likewise cover all births nationwide and the data are of good quality. We adjusted total CSs by birthweight, parity, previous CS, gestational age, singleton pregnancy, cephalic position, induction, and mother's age. The proportions of R1, R2 and R5 were adjusted by birthweight and mother's age.
However, Robson's categories do not include diagnosis and do not allow for the analysis of reasons for CS. Thus, Robson groups cannot fully explain CS trends. In addition to the analyzed factors, several other factors can influence the number of CSs; for example, mother's BMI, smoking status, education level, changes in the healthcare system, new guidelines, and the arrival of cardiotocography in obstetrics. Our data did not include these variables, which is a limitation. Further, this study also did not examine the differences in CS numbers by hospitals or by hospital levels, and it is not possible to conclude whether there are differences within the countries.
The WHO guideline clearly states that CS is a life‐saving operation for the mother and the newborn, but only if it is performed when medically indicated. 21 In both Estonia and Finland, a CS is performed only for medical necessity, and women cannot choose CS as the method of delivery. In Estonia, CS rates rose rapidly between 1992 and 2005 and remained stable in the period from 2006 to 2016. In Finland, CS rates also rose but at a much slower pace and to a lesser extent. The non‐elective CS rates, however, rose steadily in both countries. The proportion of elective CSs increased in Estonia until 2011 and in Finland until 2006, after which it started to decrease slowly. Before 2003, the total number of CSs in Estonia was lower than in Finland, after that it has remained higher.
In both countries, benchmarks are set for Robson's groups that determine target values. For example, R1 (nulliparous, single cephalic, ≥37 weeks, spontaneous labor) must be within 10%, the R2 (nulliparous, single cephalic, ≥37 weeks, induced or CS before labor) range is 20%–35% and R5 (previous CS, single, cephalic, ≥37 weeks) is 50%–60%. When grouping R1 and R2 together, they may still be within the target values. 10
This report found that R1 has been steadily increasing in Estonia, whereas in Finland R1 has been quite stable. The R2 proportion in Finland decreased, and in Estonia continued to increase for a long time but by 2016 had returned to almost the same level. However, when comparing the combined R1 and R2 rates in 2016, both countries were within the target value (Estonia 18% and Finland 16%). The two countries diverge in their R5 values. Estonia was barely within range at 59% while Finland was somewhat lower at 42%. There was a downward trend in both countries' R5 values, perhaps explained by the fact that over time the guidelines that regulate the indication of CS after a previous CS have been changed such that CS is no longer an absolute indication after the first CS. 22 Although Estonia and Finland are similar in many CS indicators, Finland has a much lower CS rate among singleton full‐term pregnancies with previous CS rate than Estonia. Other studies have indicated that if R1 + R2 rise, the total CS rate increases. 6 Changing the total CS rate requires reducing CS rates in nulliparous, single cephalic, and full‐term pregnancy (R1–R2) and increasing vaginal birth after CS. 23
Finland and Estonia are among the safest countries in the world for giving birth to both mothers and children. Estonia is an excellent example of developing perinatal and obstetric care by improving the guidelines, monitoring obstetric care indicators, having a Medical Birth Register with data collection and analysis, and a founded solidarity Health Insurance Fund to become a developing country to a developed country in 25 years. The current study enables changes in CS rates to be compared over a long period in two countries with different starting points. Estonia and Finland still have a relatively low CS rate.
5. CONCLUSION
Comparing Robson groups in different countries can shed light on divergent CS rates and to improve the quality of perinatal and obstetric care. At the national policy level, Estonia may benefit from establishing a requirement for reporting hospital‐specific Robson groups to explore underlying factors which may explain differences in CS rates between delivery units.
AUTHOR CONTRIBUTIONS
PV, MG, KS and KL designed the study. KS obtained the data from registries. KS and HP analyzed the data. All authors participated in writing and editing this article. All authors have read and approved the final manuscript.
FUNDING INFORMATION
This study received no special funding.
CONFLICT OF INTEREST STATEMENT
The authors have stated that there are no conflicts of interest.
ACKNOWLEDGMENTS
We thank Allison Krug for editing this manuscript.
Sildver K, Veerus P, Lang K, Pisarev H, Gissler M. Cesarean section trends from 1992 to 2016 in Estonia and Finland: A registry‐based study. Acta Obstet Gynecol Scand. 2023;102:1007‐1013. doi: 10.1111/aogs.14609
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