The modified Robson criteria for Caesarean Section audit at Mother and Child Health Center Pakistan Institute of Medical Sciences Islamabad

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Introduction
The World Health Organisation (WHO) in 1985 proposed that the optimal Caesarean Section (CS) rate is 10-15%.CS rate is continuing to rise worldwide in recent decades.The rise in CS rate is associated with maternal morbidity in terms of increased blood transfusions, uterine scar rupture, placenta accreta, placenta previa and hysterectomies. 1,2 understand the underlying factors associated with rising CS rate, a standard classification system of CS should be implemented. 2In 2001 came Robson's Ten Group Classification System (RTGCS) for comparing CS rates for the purpose of audit and monitoring interventions needed to reduce these rates. 1,3In 2011, a systemic review concluded that, compared to indications-based and urgency-based classifications, women-based classification systems are best for local and international use and RTGCS among these would be the most appropriate. 4It categorises women into 10 groups on the basis of 5 parameters i.e., parity, gestational age, onset of labour (spontaneous, induced or CS before labour), presentation, and number of foetuses. 5This classification system has been used in institutions across the high, medium and low income countries across the world. 7The classification was modified later by the Society of Obstetrics and Gynaecology, Canada (SOGC).This modification sub-classifies women having CS after spontaneous onset of labour, after induction of labour, and before labour. 6e crude CS rate alone is the most important indicator of obstetric care.Contrary to WHO cut-off point of 10-15% optimal CS rate, many studies have suggested that CS rates vary from one institution to another.This variation in the rates is due to difference in local resources, expertise, organisational policies and obstetric population with high-risk pregnancies, with institutions dealing with highrisk referral cases having higher CS rates. 7,8WHO multi-country survey (WHOMCS) 2010-11 in 21 countries 8 , reported a CS rate of 31.2% compared to the previous rate of 26.4% in the WHO global survey (WHOGS) 2004-08 which is significantly higher.CS rate of Sri Lanka, Brazil and Mexico, which are high on the Human Development Index (HDI), was 33%, 47% and 47.5% respectively.CS rate among moderate HDI countries was 47% for China, 39.4% for Thailand and 19.3% for India. 8akistan is a medium HDI country, and, according to Pakistan Demographic Health Survey (PDHS) 2012-13, it has a CS rate of 14%.Nigeria and Nepal, which are low HDI countries, had CS rate of 20.4% and 23.9% respectively.8,9 The current study was planned to determine the frequency of various indications of lower segment CS using modified RTGCS 6 and to identify interventions to bring the CS rate down.

Materials and Methods
The retrospective study was conducted at Pakistan Institute of Medical Sciences (PIMS), Islamabad, Pakistan, and comprised records from October 1, 2016, to September 30, 2017, related to all CS procedures.PIMS is a 1000-bed tertiary care university hospital of which the Mother and Child Health Centre (MCHC), a 150-bed facility, is a component catering to Obstetrics and Gynaecology patients.A large number of referred cases from across country are dealt with at PIMS.Data of all women who delivered during the study period was included.It was categorised using modified RTGCS on the basis of parity, previous CS, number of foetuses, presentation (cephalic/breech/other), and onset of labour (spontaneous/induced/CS before labour).
Data was collected from operation theatre (OT) and labour room records registers.Primary outcome measures were the percentage contribution of each group to overall CS rate, total deliveries in each group and relative size of each group in the obstetric population.Secondary outcome measures were primary CS rate (groups 1 and 2), repeat CS rate, trial of labour after CS (TOLAC) rate, vaginal birth after CS (VBAC) rate and CS rate of induced labour.Data was analysed using SPSS 21.The number of deliveries, sections procedures, both elective and emergency, presented as frequencies and percentages.

Discussion
CS rate is rising worldwide and progressively becoming higher in low-resource countries.RTGCS has 10 mutually exclusive categories for CS based on simple obstetric parameters.
The classification is a useful tool for the assessment of level of care and implementing interventions. 1 When comparing CS rates in different hospitals within Pakistan, it was found that the 33% CS rate in the current study was similar to Holy Family Hospital Rawalpindi (37%), but less than Fauji Foundation Hospital, Rawalpindi (49%) and Combined Military Hospital, Rawalpindi, (56%). 10All these hospitals in Rawalpindi Islamabad are receiving high-risk referrals and are not representative of the community.The lack of staff and medical facilities in district hospitals in Pakistan and a large number of self-referred obstetric patients leads to overburden in tertiary care hospitals.Some government hospitals in Pakistan are also providing private healthcare in their setups.The patient preference for mode of delivery, high incentives and risk of litigation may be the reason for the high CS rates in these hospitals.2][13] However, CS rate at PIMS was lower compared to 46.8% in Ghana, 49% in Tanzania and 46% in Egypt. 14,15 reported by other studies, groups 1, 2 and 5 were the main contributors to CS rate. 3,13,16In our study, group 5was the largest contributor with 13.8% which is high compared to 7.7% observed in WHOMCS in medium HDI countries. 8CS rate of previous scar group including CS in spontaneous labour and CS before labour ranged 51-81% in various studies. 2In our study, CS rate within group 5 was 80.3% which is high compared to 58.2%, 12 36% 17 and 61% 16 reported by other studies, but it was comparable to other studies that reported 81.4% 14 and 71%. 18However, CS rate of 80.3% for group 5 was lower than 95% observed in Tanzania. 2The variation in CS rates may be due to different management protocols of the previous scar group.Some obstetrical units do induction/augmentation of labour in previous 1 scar women whereas in many hospitals obstetricians are reluctant for VBAC due to the risk of scar rupture.The relative size of group 5 was 17% which was higher than the expected 10.1%. 16This is due to high number of CS carried out previously on nulliparous and multiparous women with singleton term pregnancies.Safe and appropriate TOLAC is the way forward to decrease group 5 CS rates. 14The adequate TOLAC rate (78%) and VBAC rate (66.7%) in PIMS will lead to reduction in group 5 CS rate and repeat CS rate.These rates in our population are similar to international reports of 67% 12 and 64%. 19In the United States (USA), the rate of TOLAC reached a nadir of 15.9% in 2006 and VBAC rate improved to 38.5% in 2008 20 which is much lower than the rate of VBAC in the current study.This low VBAC rate in the USA may be related to the litigation risks and women preference.
The relative size of group 3, multigravida in spontaneous labour, was the largest (30.7%) of the 10 groups.This finding was consistent with increased reproductive desires and fertility rate of our country. 8The size of primigravidae population classified into groups 1 and 2 was 33.2%.This is similar to 35-42% population in this group expected by Robson. 16The relative size of nulliparous women in group 1 and 2 was less than the 2:1 ratio owing to increased number of women undergoing inductions and pre-labour CS in group 2.
The CS rate for nulliparous women in spontaneous labour in group 1 was 22.2%.This rate is greater than the 10% suggested by Robson, 11% in Ghana 14 and 7.1% in Ireland. 13However, it was comparable to a study in south India and in Tanzania. 2The Primigravidae CS rate needs to be optimised in order to reduce overall CS rate.It is a lowrisk group and labour protocols should be set and appropriate management of first stage of labour is mandatory. 14Efficient uterine action should be achieved by ensuring foetal wellbeing in labour.The majority of CS procedures are carried out due to labour dystocia, so the partographic record of labour should be maintained for timely intervention and proper augmentation of labour and management should be assessed. 16e CS rate of 35.6% in nulliparous women in group 2 was comparable to 35% suggested by Robson. 13,16This is due to successful inductions and medically indicated prelabour CS in this group. 16Moreover, this is the most important group as indication of inductions should be justified because failed inductions leading to CS will increase the size of group 5 which is already the largest group.However, CS rate of 33.4% in multiparous women induced or pre-labour was higher than 13.8% in a study. 13his is because multiparous women in our hospital are usually at a very high risk as low-risk multiparous women have a trend towards home delivery or delivery at some nearby healthcare centres rather than at a tertiary care facility.The high rate of 13.8% CS in induced labour group as compared to 4-6% advised by Robson needs to be evaluated. 16High overall rate of induction of labour of 15.8% in our study compared to 11.5% in a Nigerian study, 21 elective CS due to high-risk referrals, women's request and use of CS for tubal ligation as mentioned in other studies may be the reason of high rate in this group of women. 15,22The indications for induction of labour in multiparous women and elective CS in this group should be clear and justified 13 as our rate of CS in this group is somewhat higher.
Groups 6-10 were smaller groups contributing only 5.9 % to the 33% CS rate which is comparable to 7% rate in Oman. 12The high rate of CS within groups was due to unavoidable obstetric conditions i.e. breech, multiple pregnancy, abnormal foetal lie or high-risk preterm deliveries. 13e non-cephalic group (6, 7, 9) contributed 1.96% to the CS rate which is lower than 3.8% in Ireland 13 but comparable to 2.9% in South India. 23The reluctance to perform external cephalic version (ECV) and assisted vaginal breech delivery (AVBD) has been observed in some institutions 13 so proposals for conducting hands-on practice on models and drills for ECV and AVBD should be planned.Group 9 had 100% CS rate which is the standard proposed by Robson and is a reflector of data quality. 24

Conclusion
The modified Robson classification is an effective tool for comparison of CS rates between institutions, regions and countries.It is easy to implement and interpret recommendations for reducing CS rate.Review of induction of labour and dedicated VBAC will reduce CS rates in induced labour group and previous scar group.

Disclaimer:
The text is part of a Ph.D thesis.

Table - 2
: Caesarean Section rates during the study.