Abstract
BACKGROUND
The worldwide increase in the cesarean delivery rate is a major public health concern and cause of significant debate. Although multiple studies have shown that higher cesarean delivery rates may be associated with adverse maternal and perinatal outcomes, the number of cesarean deliveries has been continuously increasing. In the Republic of Moldova, cesarean delivery increased from 15.75% in 2012 to 27.42% in 2022. However, the perinatal mortality remained unchanged at 11.6%. To understand the factors that determine the increasing trend in cesarean delivery and to approach new strategies to reduce unnecessary surgical delivery, a standardized tool is needed to assess and compare cesarean delivery rates.
OBJECTIVE
This study aimed to assess the changes in the rates and trends of cesarean delivery and to evaluate the contribution of different obstetrical populations to overall cesarean delivery rates in the Municipal Clinical Hospital using the Robson classification.
STUDY DESIGN
This was a cohort study conducted at the Municipal Clinical Hospital in Chisinau. The study included 13,882 women who gave birth in 2017, 2019, and 2022 at the Municipal Clinical Hospital. All births were classified into 10 Robson groups, using 6 basic variables (parity, cesarean delivery in medical history, labor onset, number of fetuses, gestational age, and fetal presentation). Statistical data were collected and analyzed using the Epi Info program (version 7.2.1.0; Centers for Disease Control and Prevention, Atlanta, GA).
RESULTS
The overall cesarean delivery rate was 20.02% (2779/13,882), with a significant increase from 18.59% (809/4351) to 21.59% (1134/5252) (P=.0003). Approximately one-third (1099/2279 [39.55%]) of all cesarean deliveries were performed before labor onset. The main contributor in all study years was group 5 (957/2779 [34.44%]). The next valuable group that contributed to the overall cesarean delivery rate was group 2 (393/2779 [14.14%]), followed by group 1 (333/2779 [11.98%]).
CONCLUSION
The Robson Ten-Group Classification System provides a clear and detailed record of the trends in cesarean delivery. In addition, because of the Robson Ten-Group Classification System's simplicity and exclusivity, it can be implemented in the Republic of Moldova. The main contributors to the overall cesarean delivery rate were women with a previous cesarean delivery (group 5), followed by nulliparous women of group 2 and group 1.
Key words: Ten-group classification, cesarean delivery, Republic of Moldova, Robson classification, tertiary institution, vaginal delivery
AJOG Global Reports at a Glance.
Why was this study conducted?
The trends in cesarean delivery (CD) and the contribution of different obstetrical populations to the overall CD rate were assessed using the Robson Ten-Group Classification System (TGCS) to reduce unnecessary surgical interventions.
Key findings
The main contributors to the overall CD rate were women with a previous CD (group 5), followed by nulliparous women of group 2 and group 1. The CD rate in the group of premature births (group 10) has been increasing, and premature newborns have a 2 times higher risk of being born via CD than via vaginal delivery.
What does this add to what is known?
The TGCS provides a clear and detailed record of the trends in CD. In addition, because of the TGCS's simplicity and exclusivity, it can be implemented in the Republic of Moldova.
Introduction
Cesarean delivery (CD) is one of the most common surgical interventions in obstetrics, and it is performed when certain complications occur during pregnancy or labor. However, compared with vaginal delivery (VD), CD is associated with immediate maternal and perinatal risks and long-term effects and consequences on future pregnancies when performed unnecessarily.1
Although multiple studies have shown that higher CD rates may be associated with adverse maternal and perinatal outcomes, the number of CDs has been continuously increasing, particularly in high- and middle-income countries.2,3
The reassessment of the recommended CD rate of 10% to 15%, proposed by the World Health Organization (WHO), has become more necessary because of significant improvements in clinical obstetrical care, evidence evaluation, and recommendations over the last 3 decades. The 2015 WHO public statement on CD emphasized that “every effort should be made to provide [CD] to women in need rather than [strive] to achieve a specific rate.”1,4
According to data published in 2021, worldwide CD rates have increased from approximately 7% in 1990 to 21% to date, with a projection to continue increasing over this decade. By 2030, the highest CD rates are likely to be in Eastern Asia (63%), Latin America and the Caribbean (54%), Western Asia (50%), Northern Africa (48%), Southern Europe (47%), and Australia and New Zealand (45%).5
In the Republic of Moldova, the CD rate is increasing continuously, from 15.75% in 2012 to 27.42% in 2022. However, the perinatal mortality rate remained unchanged at 11.6%. In addition, the same trend in CD was noted in the tertiary medical institution of the Municipal Clinical Hospital (MCH), where the CD rate increased significantly from 15.7% in 2012 to 22.0% in 2022 (P<.05) and the perinatal mortality rate decreased insignificantly from 8.9% in 2012 to 7.3% in 2022 (P=.302) (Figure 1).6
Figure 1.
CD rates vs perinatal mortality in the MCH, Republic of Moldova
CD, cesarean delivery rate.
Marian-Pavlenco. Cesarean delivery analysis in the institution of the Republic of Moldova. Am J Obstet Gynecol Glob Rep 2024.
CD rate increase is one of the most controversial topics in modern obstetrical practice. This phenomenon requires continuous evaluation, followed by the development and implementation of a standardized, internationally accepted classification system to monitor and compare the CD rates constantly, to understand its increasing trend, and to identify the possible causes of the continuous increase in CD rates.7
In 2015, the WHO proposed and recommended the Robson Ten-Group Classification System (TGCS) as a global standard for assessing, monitoring, and comparing CD rates in each healthcare institution and between them.1,8 Studies performed in different countries illustrated that the Robson classification is an indispensable tool for monitoring CDs in an institution and at the national level to understand the factors that determine its growth trend.9, 10, 11
This study aimed to assess the changes in the rates and trends of CD and to evaluate the contribution of different obstetrical populations to the overall CD rates in MCH using the Robson classification.
Materials and methods
This retrospective cohort study was conducted within the Department of Obstetrics and Gynecology at MCH. The study includes 13,882 women who gave birth in 2017, 2019, and 2022 at MCH. In the Republic of Moldova, the notion of “birth” includes all infants weighing ≥500g and/or with a gestational age of ≥22 weeks, alive or dead, with or without malformations, by any route.
All births were classified into 10 groups according to the WHO methodology proposed in the Robson classification manual, using 6 basic variables: parity, CD in medical history, labor onset, number of fetuses, gestational age, and fetal presentation (Appendix A). For each Robson group, the number of CDs in the group, group size and CD rate, and absolute and relative group contributions to the overall CD rate were calculated.7
The data provided in the Robson classification report table were assessed for data quality, type of population, and CD rates and were interpreted according to the standardized series of steps presented in the manual. At each stage, the results were compared with the 2 suggested sources: the reference and interpretation data by Robson and the results of the WHO Multicountry Survey on Maternal and Newborn Health (WHO MCS).7
Statistical data were collected and analyzed using the Epi Info program (version 7.2.1.0; Centers for Disease Control and Prevention, Atlanta, GA). The Pearson chi-square test was used to calculate the P value. The threshold for a P value of <.05 was considered statistically significant. The prevalence rates with 95% confidence intervals (CIs) were calculated to identify significant differences in CD rates and other variables between different periods. The estimated CD risk was defined using the common odds ratio (OR) of the Mantel-Haenszel test, with a calculation of the OR and 95%CI.
Results
The overall CD rate increased significantly from 18.59% in 2017 to 21.59% in 2022 (P=.0003). For the analysis of the rates and trends of CD, the study was conducted on a sample of 13,882 births, including 4351 births registered in 2017, 4279 births registered in 2019, and 5252 births registered in 2022. The age of all women included in the study varied between 15 and 52 years, with the average age being 29.1±0.089 years. Of note, 4616 of 13,882 women (33.25%) were between the ages of 26 and 30 years. The data from Table 1 show an absolute percentage increase of 7.19% (95% CI, 3.41%–10.75%) in women aged ≥35 years, 13.60% (592/4351) in 2017 and 20.79% (1092/5252) in 2022 (P=.0003) (Figure 2).
Table 1.
Characteristics of the obstetrical population
| Characteristic | 2017 (n=4351) |
2019 (n=4279) |
2022 (n=5252) |
Total (N=13,882) |
||||
|---|---|---|---|---|---|---|---|---|
| n | % | n | % | n | % | n | % | |
| Maternal age (y) | ||||||||
| <20 | 84 | 1.93 | 98 | 2.29 | 115 | 2.19 | 297 | 2.14 |
| 20–25 | 1160 | 26.67 | 1032 | 24.12 | 1246 | 23.72 | 3438 | 24.77 |
| 26–30 | 1549 | 35.60 | 1445 | 33.77 | 1622 | 30.89 | 4616 | 33.25 |
| 31–34 | 966 | 22.20 | 970 | 22.67 | 1177 | 22.41 | 3113 | 22.42 |
| ≥35 | 592 | 13.60 | 734 | 17.15 | 1092 | 20.79 | 2418 | 17.42 |
| Parity | ||||||||
| Nulliparous | 1950 | 44.82 | 1801 | 42.09 | 1998 | 38.04 | 5749 | 41.41 |
| Multiparous | 2401 | 55.18 | 2478 | 57.91 | 3254 | 61.96 | 8133 | 58.59 |
| Gestational age (wk) | ||||||||
| 22 0/7 to 36 6/7 | 235 | 5.40 | 187 | 4.37 | 291 | 5.54 | 713 | 5.14 |
| <28 0/7 | 9 | 3.83 | 19 | 10.16 | 19 | 6.53 | 47 | 6.59 |
| 28 0/7 to 31 6/7 | 29 | 12.34 | 25 | 13.37 | 46 | 15.81 | 100 | 14.03 |
| 32 0/7 to 36 6/7 | 197 | 83.83 | 143 | 76.47 | 226 | 77.66 | 566 | 79.38 |
| ≥37 0/7 | 4116 | 94.60 | 4092 | 95.63 | 4961 | 94.46 | 13,169 | 94.86 |
| 37 0/7 to 38 6/7 | 716 | 17.40 | 695 | 16.98 | 1007 | 20.30 | 2418 | 18.36 |
| 39 0/7 to 40 6/7 | 2635 | 64.02 | 2578 | 63.00 | 3010 | 60.67 | 8223 | 62.44 |
| ≥41 0/7 | 765 | 18.59 | 819 | 20.01 | 944 | 19.03 | 2528 | 19.19 |
| Labor onset | ||||||||
| Spontaneous | 3758 | 86.37 | 3491 | 81.59 | 3840 | 73.12 | 11,089 | 79.88 |
| Induction | 225 | 5.17 | 259 | 6.05 | 916 | 17.44 | 1400 | 10.09 |
| Prelabor CD | 368 | 8.46 | 529 | 12.36 | 496 | 9.44 | 1393 | 10.03 |
| Fetal presentation | ||||||||
| Cephalic | 4185 | 96.18 | 4066 | 95.02 | 5010 | 95.39 | 13,261 | 95.53 |
| Breech | 146 | 3.36 | 173 | 4.04 | 221 | 4.21 | 540 | 3.89 |
| Transverse/oblique | 20 | 0.46 | 40 | 0.94 | 21 | 0.40 | 81 | 0.58 |
| Number of fetuses | ||||||||
| Singleton | 4278 | 98.32 | 4214 | 98.48 | 5189 | 98.80 | 13,681 | 98.55 |
| Multiple | 73 | 1.68 | 65 | 1.52 | 63 | 1.20 | 201 | 1.45 |
| Type of delivery | ||||||||
| Vaginal | 3542 | 81.41 | 3443 | 80.46 | 4118 | 78.41 | 11,103 | 79.98 |
| CD | 809 | 18.59 | 836 | 19.54 | 1134 | 21.59 | 2779 | 20.02 |
| CD | ||||||||
| Emergency | 487 | 60.20 | 502 | 60.05 | 691 | 60.93 | 1680 | 60.45 |
| Elective | 322 | 39.80 | 334 | 39.95 | 443 | 39.07 | 1099 | 39.55 |
| Maternal conditions | ||||||||
| Diabetes mellitus | 12 | 0.28 | 15 | 0.35 | 83 | 1.58 | 110 | 0.79 |
| Hypertensive pathology | 179 | 4.11 | 177 | 4.14 | 453 | 8.63 | 809 | 5.83 |
| IVF | 19 | 0.44 | 39 | 0.91 | 44 | 0.84 | 102 | 0.73 |
CD, cesarean delivery; IVF, in vitro fertilization.
Marian-Pavlenco. Cesarean delivery analysis in the institution of the Republic of Moldova. Am J Obstet Gynecol Glob Rep 2024.
Figure 2.
Pregnancy rates by age: MCH, Republic of Moldova
Marian-Pavlenco. Cesarean delivery analysis in the institution of the Republic of Moldova. Am J Obstet Gynecol Glob Rep 2024.
The proportion of nulliparous women in the overall sample was 41.4% (5749/13,882), with an absolute percentage decrease of 6.78% (95% CI, 3.70%–9.80%) over the reference of 3 and an increase in multiparous women consequently (P<.0001) (Figure 3). At the same time, we observed an upward trend in the percentage of women who gave birth to their first child at the age of ≥35 years, from 4.41% (2017) to 5.76% (2022) (P=.05).
Figure 3.
The proportion of nulliparous and multiparous women: MCH, Republic of Moldova
Marian-Pavlenco. Cesarean delivery analysis in the institution of the Republic of Moldova. Am J Obstet Gynecol Glob Rep 2024.
Hypertensive pathology was associated with an absolute increase of 4.52% (95% CI, 3.56%–5.48%) over the years in 809 of 13,882 women (5.83%) (P<.0001). Diabetes mellitus (DM) was observed in a relatively small percentage of the obstetrical population (110 of 13,882 women [0.79%] in the general sample). However, there was a significant absolute increase of 1.30% (95% CI, 0.90%–1.69%) over the years in women with DM, from 0.28% in 2017 to 1.58% in 2022 (P<.0001) (Table 1).
Premature births (<37 weeks of gestation) were recorded in 713 of 13,882 cases (5.14%). In the general sample, this incidence did not change significantly over the study period, being 5.4% in 2017 and 5.5% in 2022 (P=.76). The proportion of extremely premature newborns (<28 0/7 weeks of gestation) was 6.59% (47/713) of the total premature births, and the proportion of newborns with severe prematurity (28 0/7 to 31 6/7 weeks of gestation) was 14.03% (100/713), with an insignificant variation during the years 2017 vs 2022 (P>.05).
Of 13,882 women, 11,103 (79.98%) gave birth vaginally, and 2279 (20.02%) gave birth via CD (Table 1). Approximately one-third (1099/2279 [39.55%]) of all CDs were performed before labor onset.
The CD rates were 43.48% (310/713) in premature gestational age cases (<37 0/7 weeks of gestation), 25.60% (619/2418) in “early term” cases (37 0/7 to 38 6/7 weeks of gestation), and 17.21% (1850/10,751) in term cases (≥39 weeks of gestation) (Table 2). Statistical analysis between the preterm (<37 weeks of gestation) and term (≥37 weeks of gestation) births revealed a significant difference in CD risk among these groups. Women who gave birth at <37 weeks of gestation were 3.3 times more likely to be operated on than those who gave birth vaginally (OR, 3.30; 95% CI, 2.85–3.89; P<.0001).
Table 2.
Risk of CD and VD depending on the term of gestation
| Gestational age (wk) | CD |
VD |
Total |
|||
|---|---|---|---|---|---|---|
| n | % | n | % | n | % | |
| <37 0/7 | 310 | 43.48 | 403 | 56.52 | 713 | 5.14 |
| 37 0/7 to 38 6/7 | 619 | 25.60 | 1799 | 74.40 | 2418 | 17.42 |
| ≥39 0/7 | 1850 | 17.21 | 8901 | 82.79 | 10751 | 77.44 |
| Total | 2779 | 20.02 | 11,103 | 79.98 | 13,882 | 100 |
| CD risk at <37 vs ≥37 wk of gestation (OR, 3.30; 95% CI, 2.85–3.89; P<.0001) | ||||||
| CD risk at 37–39 vs ≥39 wk of gestation (OR, 1.70; 95% CI, 1.50–1.84; P<.0001) | ||||||
CD, cesarean delivery; CI, confidence interval; OR, odds ratio; VD, vaginal delivery.
Marian-Pavlenco. Cesarean delivery analysis in the institution of the Republic of Moldova. Am J Obstet Gynecol Glob Rep 2024.
The probability of CD at 37 to 39 weeks of gestation was 1.7 times higher than the probability of delivery via CD at ≥39 weeks of gestation (OR, 1.70; 95% CI, 1.50–1.84; P<.0001) (Table 2).
Table 3 represents the distribution of births (13,882) among the 10 Robson groups (adapted by adding groups 2a and 2b and 4a and 4b). In this way, we can determine the prevalent groups of women in the obstetrical population and the groups that contribute the most or the least to the overall CD rate.
Table 3.
The Robson classification report table of total births
| Column 1 | Column 2 | Column 3 | Column 4 | Column 5 | Column 6 | Column 7 |
|---|---|---|---|---|---|---|
| Group | Number of CDs in the group | Number of women in the group | Group size (%) | Group CD rate (%) | Absolute group contribution to the overall CD rate (%) | Relative group contribution to the overall CD rate (%) |
| 1 | 333 | 4184 | 30.14 | 7.96 | 2.40 | 11.98 |
| 2 | 393 | 970 | 6.99 | 40.52 | 2.83 | 14.14 |
| 2a | 189 | 766 | 5.52 | 24.67 | 1.36 | 6.80 |
| 2b | 204 | 204 | 1.47 | 100.00 | 1.47 | 7.34 |
| 3 | 132 | 5689 | 40.98 | 2.32 | 0.95 | 4.75 |
| 4 | 146 | 693 | 4.99 | 21.07 | 1.05 | 5.25 |
| 4a | 33 | 580 | 4.18 | 5.69 | 0.24 | 1.19 |
| 4b | 113 | 113 | 0.81 | 100.00 | 0.81 | 4.07 |
| 5 | 957 | 1050 | 7.56 | 91.14 | 6.89 | 34.44 |
| 5.1 | 776 | 866 | 6.24 | 89.61 | 5.59 | 27.92 |
| 5.2 | 181 | 184 | 1.33 | 98.37 | 1.30 | 6.51 |
| 6 | 251 | 265 | 1.91 | 94.72 | 1.81 | 9.03 |
| 7 | 186 | 221 | 1.59 | 84.16 | 1.34 | 6.69 |
| 8 | 134 | 201 | 1.45 | 66.67 | 0.97 | 4.82 |
| 9 | 62 | 63 | 0.45 | 98.41 | 0.45 | 2.23 |
| 10 | 185 | 546 | 3.93 | 33.88 | 1.33 | 6.66 |
| Total | 2779 | 13,882 | 100.00 | 20.02 | 20.02 | 100.00 |
Marian-Pavlenco. Cesarean delivery analysis in the institution of the Republic of Moldova. Am J Obstet Gynecol Glob Rep 2024.
According to the data presented in column 4, regarding the relative size of each group, group 3 (multiparous women with a single cephalic pregnancy at ≥37 weeks of gestation in spontaneous labor, without a previous uterine scar) had the largest contribution to the total obstetrical population at 40.98% (5689/13,882), followed by group 1 (nulliparous women with single cephalic pregnancy at ≥37 weeks of gestation in spontaneous labor) at 30.14% (4184/13,882). Group 5 (multiparous women with single cephalic pregnancy at ≥37 weeks of gestation, with a previous uterine scar) was the third largest group at 7.56% (1050/13,882), followed by group 2 (nulliparous women with single cephalic pregnancy at ≥37 weeks of gestation with induced labor or prelabor CD) at 6.99% (970/13,882) (Table 3). These groups are the most representative obstetrical groups in all studied years (Table 4).
Table 4.
Contribution of each Robson group to the total obstetrical population
| Group | Total | 2017 | 2019 | 2022 |
|---|---|---|---|---|
| 1 | 30.14 | 35.99 | 32.10 | 23.71 |
| 2 | 6.99 | 4.46 | 5.60 | 10.20 |
| 2a | 5.52 | 3.13 | 3.40 | 9.21 |
| 2b | 1.47 | 1.33 | 2.20 | 0.99 |
| 3 | 40.98 | 40.75 | 42.40 | 39.99 |
| 4 | 4.99 | 2.23 | 3.50 | 8.53 |
| 4a | 4.18 | 1.72 | 2.20 | 7.79 |
| 4b | 0.81 | 0.51 | 1.20 | 0.74 |
| 5 | 7.56 | 6.92 | 7.50 | 8.13 |
| 6 | 1.91 | 1.77 | 2.20 | 1.81 |
| 7 | 1.59 | 1.33 | 1.40 | 1.96 |
| 8 | 1.45 | 1.68 | 1.50 | 1.20 |
| 9 | 0.45 | 0.37 | 0.70 | 0.36 |
| 10 | 3.93 | 4.50 | 3.10 | 4.11 |
Marian-Pavlenco. Cesarean delivery analysis in the institution of the Republic of Moldova. Am J Obstet Gynecol Glob Rep 2024.
The percentage change in the CD rate in each Robson group within 5 years is illustrated in Figure 4, with a significant increase in most groups—group 1 by 2.54%, group 7 by 10.99%, group 8 by 9.35%, and group 10 by 4.85%—and a significant decrease in groups 2 and 4 by 15.61% and 13.78%, respectively.
Figure 4.
CD rate according to the Robson groups: MCH, Republic of Moldova
Marian-Pavlenco. Cesarean delivery analysis in the institution of the Republic of Moldova. Am J Obstet Gynecol Glob Rep 2024.
Of all women in group 10 (all single cephalic pregnancy, <37 weeks of gestation), one-third (185/546 [33.88%]) gave birth via CD. The CD rate in this group had an absolute increase of 4.80% (95% CI, 2.93%–6.76%; P<.0001), from 32.7% in 2017 to 37.5% in 2022.
When comparing the types of labor between group 10 and the other Robson groups, the data showed that preterm neonates (<37 weeks of gestation) were 2.1 times more likely to be born via CD than via VD (OR, 2.10; 95% CI, 1.77–2.55; P=.00001) (Table 5).
Table 5.
Evaluation of CD and VD risk in group 10
| Variables | CD |
VD |
Total |
|||
|---|---|---|---|---|---|---|
| n | % | n | % | n | % | |
| Group 10 | 185 | 7.1 | 361 | 3.4 | 546 | 4.1 |
| Other groups | 2594 | 92.9 | 10,742 | 92.6 | 13,336 | 95.1 |
| Total | 2779 | 20.0 | 11,103 | 80.0 | 13,882 | 100.0 |
| CD risk in group 10 vs other groups (OR, 2.10; 95% CI, 1.77–2.55; P=.00001) | ||||||
CD, cesarean delivery; CI, confidence interval; OR, odds ratio; VD, vaginal delivery.
Marian-Pavlenco. Cesarean delivery analysis in the institution of the Republic of Moldova. Am J Obstet Gynecol Glob Rep 2024.
Analyzing the relative contribution of each group to the overall CD rate (column 7), group 5 was determined to be the biggest contributor at 34.44% (957/2779) and the main contributor in all study years. In the group of women with a single uterine scar (group 5.1), we found that, in more than half, CD was performed before labor onset: 64.34% (157/244) in 2017, 76.96% (177/230) in 2019, and 63.25% (191/302) in 2022.
In the group of women with 2 or more uterine scars (group 5.2), the relative contribution of the group to the overall CD rate was a significant absolute increase of 4.18% (95% CI, 2.00%–6.30%) during study years (P=.0003) Table 6).
Table 6.
Relative contribution of the Robson groups to the overall cesarean delivery rate
| Group | Total | 2017 | 2019 | 2022 |
|---|---|---|---|---|
| 1 | 11.98 | 14.22 | 11.40 | 10.85 |
| 2 | 14.14 | 11.62 | 14.70 | 15.52 |
| 2a | 6.80 | 4.45 | 3.50 | 10.93 |
| 2b | 7.34 | 7.17 | 11.30 | 4.59 |
| 3 | 4.75 | 6.43 | 4.00 | 4.14 |
| 4 | 5.25 | 3.34 | 6.70 | 5.56 |
| 4a | 1.19 | 0.62 | 0.50 | 2.12 |
| 4b | 4.07 | 2.72 | 6.20 | 3.44 |
| 5 | 34.44 | 34.36 | 33.80 | 35.01 |
| 5.1 | 27.92 | 30.16 | 27.50 | 26.63 |
| 5.2 | 6.51 | 4.20 | 6.20 | 8.38 |
| 6 | 9.03 | 9.15 | 10.20 | 8.11 |
| 7 | 6.69 | 5.69 | 5.60 | 8.20 |
| 8 | 4.82 | 5.32 | 5.70 | 3.79 |
| 9 | 2.23 | 1.98 | 3.20 | 1.68 |
| 10 | 6.66 | 7.91 | 4.80 | 7.14 |
Marian-Pavlenco. Cesarean delivery analysis in the institution of the Republic of Moldova. Am J Obstet Gynecol Glob Rep 2024.
The second valued contributor to the overall CD rate was group 2 at 14.14% (393/2779), followed by group 1 at 11.98% (333/2779).
Analyzing the relative contribution of groups 1 and 2 over time, we found that group 1 had a higher relative contribution (14.22%) to the overall CD rate than group 2 (11.62%) in 2017 and group 2 (14.7%) had a higher proportion than group 1 (11.4%) in 2019. In 2022, group 2 maintains its position with a contribution of 15.52% to the total CD rate, and group 1 has a contribution of 10.85% to the total CD rate (Figure 5).
Figure 5.
Dynamics of the relative contribution of the Robson groups to the overall CD rate: MCH, Republic of Moldova
Marian-Pavlenco. Cesarean delivery analysis in the institution of the Republic of Moldova. Am J Obstet Gynecol Glob Rep 2024.
Comment
Principal findings
Although the CD rate in MCH showed a significant absolute increase of 6.3%, the perinatal mortality rate showed an insignificant decrease of 1.6% in the last 10 years.
The overall CD rate was 20.02% during the study period. The biggest contributors to the overall CD rate in our population were women with a uterine scar after at least 1 previous CD (group 5), followed by nulliparous women with a single cephalic at term pregnancy who had an induced labor or prelabor CD (group 2) and nulliparous women with single cephalic at term pregnancy who had spontaneous labor (group 1).
The proportion of nulliparous women in the overall sample has a significant percentage decrease. At the same time, we observed an upward trend in the percentage of women who gave birth to their first child at the age of ≥35 years.
Results in the context of what is known
The Republic of Moldova has a considerable decrease of more than 12,000 births in the last decade, from 39,879 births in 2012 to 27,212 births in 2022.6 The CD rate has an absolute increase of 11.7% in the last 10 years. This CD rate increase is higher than in some European and non-European countries, regardless of their level of development. However, the overall CD rate in our country remains comparatively lower.9, 10, 11, 12, 13, 14
The main contributors to the total number of our obstetrical population were multiparous women with spontaneous labor (group 3) at 40.98%, nulliparous women with spontaneous labor (group 1) at 30.14%, and women with uterine scar after CD (group 5) at 7.56%, with an insignificant difference from year to year. This correlates with data from studies conducted in European countries, Brazil, and Thailand that reported that groups 3, 1, and 5 were the most representative groups. Group 5 is third in terms of size and the main contributor to the overall CD rate, with a value of 34.44%, which corresponds to the data presented in other studies in the specialized literature.12,13,15
Clinical implications
In the obstetrical population included in the study, the proportion of nulliparous women from groups 1 and 2 (38.1%) was lower than the proportion of multiparous women from groups 3 and 4 (46.5%). At the same time, a decrease in time of the nulliparous population (groups 1 and 2) was observed, from 40.4% in 2017 to 33.91% in 2022, falling below the Robson interpretation level (35%–42%). In addition, the statement regarding the reduction of the nulliparous population is confirmed by the decreasing ratio of women with a single breech pregnancy (group 6/group 7) from 1.4 in 2017 to 0.9 in 2022.
Nulliparous women have an increase in the obstetrical risk, which can be explained by the consistent decrease in the ratio between group 1 and group 2 from 7.97 in 2017 to 2.3 in 2022, reaching a lower level than that recorded in the reference population (3.3).7
In our population, the high CD rate of 91.14% in group 5, with a peak of 92.97% in 2022, markedly contrasts with the rates of 50% to 60% considered adequate by Robson and 74.4% obtained in the WHO MCS study. This phenomenon is due to the significant increase in the relative contribution of group 5.2 (women with 2 or more previous CDs) to the overall CD rate in 2022 compared with 2017 by 4.18%. In addition, this fact can be explained by the policy of scheduling prelabor CD for women with a uterine scar (group 5.1) without attempting a trial of labor. In more than half of women with 1 uterine scar, the CD was performed before labor onset. This can explain the increasing contribution of group 5.2 as a consequence.
Before recommending a vaginal birth after cesarean delivery (VBAC), an assessment of the hospital's ability to provide a safe labor process for women with a uterine scar is crucial. Moreover, the lack of information about the previous CD (how it was performed or the presence or absence of surgery complications) may determine the obstetrician's hesitation to recommend VBAC.
The ratio between spontaneous and induced deliveries in nulliparous women (group 1/group 2) has decreased over the 5-year period from 7.97 in 2017 to 2.30 in 2022. Similarly, the ratio between spontaneous and induced deliveries in multiparous women (group 3/group 4) decreased from 18.50 in 2017 to 4.69 in 2022. The high ratio rates between these groups in 2017 indicated the need to increase the number of induced births in groups 2 and 4, which is an argument for reviewing the national guidelines for labor induction. The correct selection of women requiring labor induction in the following years is reflected by the decrease in the CD rate from 48.50% to 32.84% in group 2 and from 27.80% to 14.06% in group 4.
The CD rates in group 10 (all single cephalic pregnancies at <37 weeks of gestation) of 32.7% in 2017 and 37.5% in 2022 are above the Robson level of interpretation (30.0%) and the WHO MCS population (25.1%). The preterm neonates of group 10 were 2.1 times more likely to be born via CD than via VD. This phenomenon can be explained by the increase of high-risk pregnancies in the population (eg, DM or hypertensive disorders) that require a preterm prelabor CD.
Research implications
The analysis of the rates and trends of CD using the Robson TGCS identified the groups of women that contributed the most to the increase of the CD rate in the Republic of Moldova. This is a solid basis for further research on the causes of high CD rates and to approach new strategies to reduce unnecessary surgical delivery.
In our population, the probability of delivery via CD at the “early term” of gestation was 1.7 times higher than the probability of delivery via CD at term. Considering that CD performed at “early term” (37–39 weeks of gestation) has an increased risk of neonatal complications compared with elective CD performed after 39 weeks of gestation,16 a future analysis is needed to identify cases of CD that can be postponed after 39 weeks of gestation.
The increase in the CD rate in group 10 suggests many cases of high-risk pregnancies. This fact requires a more detailed analysis of the group to identify the factors that influence a preterm prelabor CD.
Strengths and limitations
The strength of this study is that the Robson classification is a firm and easily applicable tool to assist in the critical analysis of CD rates that can be used in the Republic of Moldova. As this study was conducted in 3 different years, 5 years apart, it provides an objective and relevant view of the trends in CD and identifies obstetrical population groups that can determine its growth trend.
The limitations of this study are the large study population and the manual introduction of data in the Epi Info questionnaire, although our data quality corresponds to the Robson Interpretation Steps to assess the quality of data.
Conclusions
The Robson TGCS provides a clear and detailed record of the trends in CD. Because of the TGCS's simplicity and exclusivity, it can be implemented in the Republic of Moldova.
The overall CD rate was 20.02%, with the main contributor group being women with a uterine scar (group 5), followed by nulliparous women of group 2 and group 1.
The CD rate in the group of women with premature delivery (group 10) has been increasing by 4.8% in 5 years, and premature newborns have 2 times higher risk of being born via CDs than via VD.
The proportion of nulliparous women in our obstetrical population decreased significantly by 6.78%. At the same time, there is an increasing trend of women giving birth to their first child at the age of >35 years.
CRediT authorship contribution statement
Angela Marian-Pavlenco: Writing – review & editing, Writing – original draft, Supervision, Resources, Project administration, Methodology, Formal analysis, Data curation, Conceptualization. Irina Siritanu: Writing – review & editing, Writing – original draft, Formal analysis, Data curation, Conceptualization. Tatiana Ribac: Formal analysis, Data curation. Valentin Friptu: Visualization, Validation, Supervision.
Footnotes
The authors report no conflict of interest.
The authors have obtained both informed consent and ethics committee approval for studies on patient records.
Cite this article as: Marian-Pavlenco A, Siritanu I, Ribac T, et al. Cesarean delivery in a tertiary institution of the Republic of Moldova: analysis using the Robson classification. Am J Obstet Gynecol Glob Rep 2024;XX:x.ex–x.ex.
Supplementary material associated with this article can be found in the online version at doi:10.1016/j.xagr.2024.100408.
Appendix. Supplementary materials
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