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Variation in caesarean section rates according to the Robson classification in four low- and middle-income countries:
Marion Ravit1, Camille Etcheverry2, Charles Kabore3
1Université Paris Cité and Université Sorbonne Paris Nord, IRD, Inserm, CepedUniversité Paris Cité and Université Sorbonne Paris Nord, IRD, Inserm, Ceped, Paris, France, 75006, France. marion.ravit@ird.fr.
Background:
Caesarean section (CS) rates have increased globally, with substantial variations across healthcare settings. Monitoring CS rates using Robson's Ten Group Classification System (RTGCS) provides insights into obstetric practices. This study examines the variation in CS rates among women classified in Groups 1 to 4 of the RTGCS across hospitals in four low- and middle-income countries (LMICs) and explores hospital-level factors associated with these variations.
Methods:
This observational study analyzed CS rates in 32 hospitals (8 per country) in Argentina, Burkina Faso, Thailand, and Vietnam. Data were collected from hospital records between January and December 2020. A meta-analysis assessed hospital-level heterogeneity in CS rates, and meta-regression models explored potential determinants, including hospital characteristics such as staffing levels, equipment availability, and birth volume.
Results:
The overall CS rate in the 32 hospitals was 45.4%, with nearly half (46.5%) of CS performed on women in Groups 1 to 4. There was substantial heterogeneity in CS rates among hospitals (I2 > 75%, p < 0.001). Factors associated with variations included country differences, staffing levels (midwife-to-delivery and doctor-to-delivery ratios at night), the presence of functional equipment (ultrasound and cardiotocograph), birth volume, and the possibility of labor companionship. Hospitals with higher birth volumes and greater staff availability had higher CS rates, while those permitting companionship during labor exhibited lower rates.
Conclusions:
Hospital characteristics appear to influence CS rates among low-risk groups, highlighting the need to consider institutional factors when implementing CS reduction strategies. Routine monitoring using the RTGCS, alongside tailored interventions addressing hospital-specific challenges, could support efforts to optimize CS use in LMICs. Further research is needed to confirm the role of organizational factors and guide policy decisions.
Trial Registration:
The QUALI-DEC trial is registered with the Current Controlled Trials database (ISRCTN67214403), registration date: 30/03/2020.
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