Use of indications to identify appropriate caesarean section rates
Authors: Michael Stephen Robson
Journal: The Lancet Global Health (2018)

Appropriate caesarean section rates and the methods used to identify them continue to be controversial. The prevalence of caesarean section is increasing in most countries, and is exceptionally high in some countries, whereas in others caesarean sections have remained relatively infrequent often because of lack of access to the procedure. The article by José M Belizán and colleagues1Belizán JM Minckas N McClure EM et al.An approach to identify a minimum and rational proportion of caesarean sections in resource-poor settings: a global network study.Lancet Glob Health. 2018; 6: e894-e901Summary Full Text Full Text PDF PubMed Scopus (24) Google Scholar in The Lancet Global Health has looked into trying to identify a minimum and rational caesarean section rates in resource-poor settings. Determining appropriate numbers of caesarean sections is a global problem and any method that can be used to identify a minimum and rational number of caesarean sections needs careful scrutiny. It should contain contributions from both non-clinical and clinical stakeholders, particularly those with an active interest and responsibility for perinatal auditing. Consensus must be achieved to move forwards and there must be recognition that routine data collection remains the biggest current challenge to the future of good quality perinatal care. The study used six potentially lifesaving indications for caesarean section and, using a literature review, identified 20 articles of varying types to calculate the rates of caesarean section of these indications. They considered that an acceptable rate would be between the 25th and the 75th percentile of the distribution found in the literature review. They then analysed a large prospective population-based database from six low-income and middle-income countries (Global network site 2010–13) to identify the rates of caesarean section by indication for each site and related it to the incidence of reported obstetric complications in the same population. Caesarean section rates should always be interpreted in context and especially with information on the incidence of perinatal and maternal mortality, which was not available to the authors of this study. If a minimum and rational caesarean section prevalence is being suggested, then there needs to be information on the incidence of stillbirths in the population being examined. Stillbirths can only be prevented by inducing labour or delivering by pre-labour caesarean section, both of which will increase the overall number of caesarean sections. Studies that have recommended a caesarean section rate of 10–15% as appropriate in the past have not included numbers of stillbirths in their calculations and instead refer only to neonatal mortality rates.2Ye J Zhang J Mikolajczyk R Torloni MR Gülmezoglu AM Betran AP Association between rates of caesarean section and maternal and neonatal mortality in the 21st century: a worldwide population-based ecological study with longitudinal data.BJOG. 2016; 123: 745-753Crossref PubMed Scopus (166) Google Scholar The reason given for this is that this information is not widely available; if that is the case then it is difficult to agree a minimum and rational number of caesarean sections. Using indications for classification of caesarean sections as the initial and only arbitrator brings with it some problems.3Robson MS Classification of caesarean sections.Fetal Matern Med Rev. 2001; 12: 23-39Crossref Scopus (262) Google Scholar Indications are poorly defined (prolonged or obstructed labour), often multiple, and inconsistently applied. They are also always retrospective in the sense that they do not identify prospectively the group of women that will be most susceptible to that particular complication or indication for caesarean section. Prospective identification is essential if true comparison of numbers of caesarean section are going to occur and improvements in care implemented. Finally, there is often overlap between indications, especially when different hierarchical measurements such as breech and prolonged labour or breech and previous caesarean section are used as two different indications. Another example is if a fetus develops suspected distress after oxytocin is given: in that case, is the indication fetal or dystocia, especially if there is no fetal problem once the oxytocin is stopped? Is it distinguished from suspected fetal distress without the administration of oxytocin? Currently there is no clear accepted method described for deciding in which group the caesarean sections in question should be placed. Comparison of perinatal data must always start at the level where consensus agreement is present and for which it is easiest to obtain data. Attempts to endorse a classification of indications for caesarean sections from a clinician's point of view remain elusive. Even if there was an agreement of a classification of indications there remain other problems in its use as the initial and primary arbitrator. First, the relative incidence of nulliparous and multiparous (women with and without a scar after caesarean section) women directly affects not only the overall prevalence of caesarean section but also that of some indications and complications, for example pre-eclampsia, uterine rupture, and others. The prevalence in the population of single cephalic, breech, transverse (or oblique lie), and multiple pregnancies likewise will also affect these incidences as will ethnic origin and other epidemiological variables. In modern clinical practice, any classification of indications for caesarean section has to distinguish between pre-labour caesarean sections and those after spontaneous and induced labour.3Robson MS Classification of caesarean sections.Fetal Matern Med Rev. 2001; 12: 23-39Crossref Scopus (262) Google Scholar The same classification cannot be used for both types of caesarean section. The reason for this is that a prelabour caesarean section is carried out for a medical or pregnancy condition while a caesarean section after spontaneous or induced labour is essentially for either failure to progress (dystocia) or suspected fetal distress, and rarely for the condition that prompted the induction of labour. For example, an induction might be initiated for one indication (for example pre-eclampsia), but caesarean section is done for prolonged labour or fetal distress. What becomes the indication for caesarean section in that case? The logical approach at the present time is to apply indications for caesarean section as currently recorded (until there is more consensus) to different groups of women within a prospective classification5Robson M Hartigan L Murphy M Methods of achieving and maintaining an appropriate caesarean section rate.Best Pract Res Clin Obstet Gynaecol. 2013; 27: 297-308Crossref PubMed Scopus (107) Google Scholar as a common starting point.6Robson M The Ten Group Classification System (TGCS)—a common starting point for more detailed analysis.BJOG. 2015; 122: 701Crossref PubMed Scopus (31) Google Scholar The Ten Group Classification System (TGCS) is already being used in more than 50 countries and has been endorsed by WHO,7Betran AP Torlini MR Zhang JJ Gulmezoglu AM et al.WHO Statement on caesarean section rates.BJOG. 2016; 123: 667-670Crossref PubMed Scopus (346) Google Scholar International Federation of Gynecology and Obstetrics,8FIGO StatementBest practice advice on the 10-Group Classification: system for cesarean deliveries. FIGO Working Group on Challenges in Care of Mothers and infants during Labour and Delivery.Int J Gynecol Obstet. 2016; 135: 232-233Crossref PubMed Scopus (24) Google Scholar and the European Board of Obstetrics and Gynaecology.9European Board and College of Obstetrics and GynaecologyEBCOG position statement on caesarean section in Europe.Eur J Obstet Gynecol Reprod Biol. 2017; 219: 129PubMed Google Scholar The methodology used by the TGCS has an advantage that because of its structure it is able to self-validate the quality of data and uses a method that is simple to follow.10WHORobson Classification: implementation manual. World Health Organization, Geneva2017Google Scholar The TGCS can incorporate other labour and delivery events, outcomes, morbidity, and mortality and this preliminary stratification prior to applying the indications for caesarean section will overcome most of the problems previously described in identifying a minimum rational caesarean section rates. If the lack of good quality routinely collected information is the reason why this cannot be done then this needs to be recognised and overcome. It is time for a new way of thinking.11Robson M The 10-Group Classification System-a new way of thinking.Am J Obstet Gynecol. 2018; 219: 1Summary Full Text Full Text PDF PubMed Scopus (15) Google Scholar This online publication has been corrected. The corrected version first appeared at thelancet.com/lancetgh on July 16, 2018 This online publication has been corrected. The corrected version first appeared at thelancet.com/lancetgh on July 16, 2018 I report no competing interests other than my name having been attached to the Ten Group Classification System and that I was responsible for constructing it. An approach to identify a minimum and rational proportion of caesarean sections in resource-poor settings: a global network studyIn the site with high caesarean section prevalence, more than half of the procedures were not done for life-saving conditions, whereas the sites with low proportions of caesarean section (below 9%) had an insufficient number of caesarean procedures to cover those life-threatening causes. Attempts to establish a minimum caesarean prevalence should go together with focusing on the life-threatening causes for the mother and child. Simple methods should be developed to allow timely detection of life-threatening conditions, to explore actions that can remedy those conditions, and the timely transfer of women with those conditions to health centres that could provide adequate care for those conditions. Full-Text PDF Open AccessCorrection to Lancet Glob Health 2018; 6: e820–21Robson M. Use of indications to identify appropriate caesarean section rates. Lancet Glob Health 2018; 6: e820–21—In this article, the copyright line should read "Crown Copyright © 2018 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license.". This correction has been made as of July 16, 2018. Full-Text PDF Open Access