PRECIS: Total and primary CS rates between 2018-2023 were 57.55, 28.83% respectively and Robson Groups 1-4 groups constituted 58% of cesarean sections.

Introduction

The cesarean section (CS) is an operative mode of delivery that can be lifesaving for the mother and fetus under certain circumstances. However, as it is an operation itself; contains various risks and possible complications that may be encountered. CS rates continue to rise globally, especially in middle- and high-income countries during the last few decades⁽¹⁾. This increase has been attributed to various factors that may vary across most countries^(1,2,3). When medically necessary, CS effectively prevents perinatal mortality and morbidity. However, in cases where CS is not necessary, there is no evidence showing the benefit of CS for the mother or child.

In recent years, governments and clinicians have expressed concerns about the increasing number of cesarean deliveries and the potential negative consequences of CS for maternal and child health⁽⁴⁾. In addition, the cost is an important factor for equitable access to resources in improving maternal and newborn health, and cesarean deliveries pose a serious financial burden, especially on overburdened and often weak health systems, as they require more expenditure.

Since the World Health Organization (WHO) has determined the acceptable CS rate should not be more than 10-15% there has been a necessity for a classification system of cesareans to analyze and make proper comparisons between countries or even different hospitals or healthcare systems⁽⁵⁾. The most challenging part in defining the optimum cesarean rate is the lack of a reliable and internationally accepted classification system to produce standardized data in providing a tool that can be used to compare populations at any level and to investigate the increasing trend of cesarean rates. In 2001, the system proposed by  Robson⁽⁶⁾ stratified women according to their obstetric characteristics so that comparisons can be made with fewer confounding factors. This system classifies women independently into ten different groups based on five basic birth characteristics. This classification is simple, reliable, reproducible, clinically significant, and prospective in every woman presenting for delivery. Allows the comparison and analysis of CS rates within and between groups⁽⁷⁾. To control and provide acceptable rates for CS globally, the WHO made a statement regarding the use of the Robson classification as a global reporting tool for CS rates^(7,8). Moreover, in 2013, a cross-sectional study; “The WHO Multicountry Survey on Maternal and Newborn Health” was published, implementing data from 29 countries to settle reference values for CS rates that are globally applicable. Based on WHO MCS, another study was conducted to create mathematical modeling for reference value generation for the health facilities of each country^(9,10).

Unfortunately, Turkey has the highest CS rates globally and has been rising over the years since the last decade⁽¹¹⁾. This study aims to assess CS rates between 2018 and 2023 using National Health Data and to analyze them according to the Robson classification system and WHO reference values to discuss possible measures against increasing rates.

Materials and Methods

The Ministry of Health in Turkey has been analyzing CS rates since 2014 through the electronic registration system. The system takes information from the hospitals’ electronic automation system, which includes data on obstetric outcomes, Robson classification, and birth certificates from the state (public), private, and university hospitals all over Turkey. Robson’s woman-based totally inclusive and mutually exclusive 10-group classification employs simple clinical obstetrical parameters (parity, previous CS, gestational age, the onset of labor, fetal presentation, and number of fetuses). In the present study, we assessed the rates of CS delivery for each year between 2018 and 2023; the CS rate including all 5-years, and analysis of CS rates for each Robson group as advocated by WHO. We aimed to evaluate the contribution of each Robson group to the CS rate and calculate how much deviation there is from the global reference values prescribed by the WHO. Also, another assessment was done of the facilities where the CSs were applied (public, private, or university hospitals); therefore, it would be important to reveal the contribution of different kinds of stakeholders and to shed light on solution suggestions for reducing the CS rates.  This cohort has been undertaken by the Ministry of Health through a specific circular. Data collection permission was granted from the Ministry of Health.

Statistical Analysis

We performed the statistical analysis with the Statistical Package for Social Sciences (SPSS 26.0 IBM SPSS Inc., Chicago, IL) program. Demographic data are presented as numbers with percentages (%). To determine the statistical difference between categorical data (Robson group cesarean rates among facilities), we used the Pearson chi-square test and presented the crude odds ratio. Risk ratio/relative risk was also calculated for a more detailed presentation. Statistical significance of the p-value accepted as p<0.05 at 95% confidence interval.

Results

The total number of births recorded between May 2018 and June 2023 was 6.161.976. The overall CS rate between 2018 and June 2023 was 57.55 %. The number of total CS operations performed was 3.546.049. The primary CS rate was 28.83%, which means that 1.776.503 primary CSs were performed during this period. According to the WHO MCS population reference calculation, the number of CSs and primary CS operations were expected as 1.833.116 and 754.039 respectively⁽¹⁰⁾.  However, in our country, the number of applied CSs was approximately twice the value.

Robson Classification of the CSs

The classification of the CS numbers according to the Robson Classification System is shown in Table 1. Robson groups 1,2,3 and 4 comprised 58.4% of all CSs. Another analysis of the CSs shows the rates disaggregated according to the health facilities (public, university, and private hospitals) where CSs are performed (Table 2). Also, the risk ratios and odds ratios for having a CS based on the health facility are detailed in Table 2. This analysis revealed the risk of having CS in a group of patients with similar characteristics when applied to a different kind of health facility. Table 3 shows pairwise comparisons of centers for each Robson group in terms of CS rates (Public vs. University, public vs private, and private vs university). When the centers were compared with each other, significant differences were observed in each Robson group, especially between the public and private centers.

When Robson group 1 was examined from this viewpoint, it was seen that the CS rate was significantly higher than the reference values according to WHO. The total risk ratio was calculated as 5.80. Among this group, admission to a private hospital was associated with significantly higher cesarean rates. Examination of Robson group 2 revealed that the CS rate was found to be higher compared to the reference values of WHO. In this group, the highest risk rate for CS was found in university hospitals. It was observed that the total risk ratio was 8.18. The highest risk of having CS was found to be 33.43 in private hospitals. In university-based hospitals, the risk ratio is 23.23; and the odds ratio was calculated as 33.15.

In the Robson 4 group, while public hospitals showed compatible results with the reference values, a 6.34 risk ratio was calculated in university hospitals (odds ratio: 7.27). In the Robson 5 group, the CS rate was again significantly higher than the reference values. 97.9% of the women who had a previous CS had a repeat CS operation.

CS rates in the Robson 6,7,8,9 groups were consistent with the expected reference values. Women with a breach presentation (Groups 6 and 7); underwent CS with percentages of 97.6% and 95.2%, respectively. CS rates of Robson group 10 in all three kinds of health facilities were also significantly higher than the WHO reference values.

Table 3 shows pairwise comparisons of centers for each Robson group in terms of CS rates (Public vs University, public vs private, and private vs university). When the centers were compared with each other, significant differences were observed in each Robson group, especially between the public and private centers.

Discussion

This study is the largest cohort study conducted in Turkey to date, which constitutes the National Data of the 5-year period. Data from more than 6 million deliveries and more than hundreds of healthcare facilities are analyzed and categorized according to the Robson classification system. The overall and primary CS rates between 2018 and June 2023 were 57.55% and 28.83%, respectively. When analyzed according to the ten groups of Robson, it was found that Groups 1-4 constituted 58.4% of all CSs. These four groups represent women who are more than 37 weeks pregnant without any previous CSs and have no presentation anomalies that make them proper candidates for vaginal delivery. However, more than half of this population has had primary CS with various indications. According to WHO reference values, almost two-thirds of these women should not have had a CS⁽¹⁰⁾. According to the available records, it is not possible to determine whether the cause of these CSs is due to an indicative situation that occurred during labor or the preference of the patient or the physician.

Our analysis determined significant differences between different healthcare facilities regarding CS rates. We presented this difference as risk ratio and odds ratio, which clearly revealed that admission to a private hospital is associated with the possibility of a CS more than either university or public hospitals on its own. This finding is compatible with the previous study by Eyi et al.⁽¹²⁾. In their study, they analyzed CS rates for 2017 over the National Health Record System and found overall CS rates as 51.2%. The CS rate in private hospitals was 70.6%, which was higher than that in university and public hospitals. This finding may actually be related to some CS cases applied upon maternal request.  As previously mentioned, increasing childbearing age, fear of childbirth, and sexual concerns may affect women’s preferences on the mode of delivery^(13,14). The debate continues about whether the mother has the right to request CS. Several guidelines still advocate that CS should be applied under certain medical circumstances related directly to the health of the mother or fetus, but some support the woman’s right to decide^(14,15).

Perhaps the most predictable of these findings is the increasing number and so the rate of women with previous CSs (Group 5). It is inevitable that the increase in the numbers in groups 1-4 will create serious accumulation in group 5 over the years. Women who had at least one CS (group 5) accounted for more than a quarter of all CSs. These women seem to be inevitably going through CS as the rate among them is 97.9%. Vaginal birth after CS seems to have a very low rate of 2.1%, which is clearly lower than in other countries as the rate of VBAC is approximately 10% in the USA⁽¹⁶⁾, rising to 45-55% in Finland, Sweeden and Netherlands⁽¹⁷⁾. In the literature, evidence-based data support VBAC as a safe procedure that is applicable to many women under certain circumstances. However, there are still several concerns on both the patient and clinician sides⁽¹⁸⁾. Knowing that encouraging VBAC may be one of the important strategies on the way to reducing CS rates; it is not so easy to achieve the goal until all the question marks are clear⁽¹⁸⁾. The decision process of women should be held professionally, including proper guidance and clarity about safety information. For the clinician, healthcare organizational support, teamwork ability, and clarification of the issue in the legislation system for medicolegal concerns are all truly important in reducing anxiety^(19,20).

As mentioned before, Turkey is a country with the highest CS rates. South American countries are the others with almost similar rates. In Brazil the overall CS rate was reported as 55.8%, and Group 5 had the highest contribution to the total numbers⁽²¹⁾. The same group in another paper stated that the high number of lawsuits and medicolegal issues prompted doctors to adopt a defensive approach while managing obstetric patients and as a result do more CSs⁽²²⁾. This may be attributable to our country as well. In the USA, the overall CS rate was 31.6%, having the highest contribution from Group 5⁽²³⁾.

The main strength of this study is being conducted on the largest population to date regarding overall CS rates and their Robson classification in Turkey. The previous reviews of National Data contained one-year projections⁽¹²⁾. Besides, of course, it is not free from some limitations. Working on big data has several challenges, as it is hard to get every single detail needed. National data come from more than one thousand facilities, and it is sometimes hard to standardize the recording ability and clarity. Despite all the difficulties, high numbers of patients allow researchers to reach better conclusions and make better comments on the big picture of a certain issue⁽²⁴⁾.

Conclusion

The use of the Robson classification system while recording and reporting the CSs provides a global tool to improve perspectives for reducing the rates. Based on the National Data from Turkey, there are groups that deserve to act. Groups 1-2 represent (Nulliparous, single, cephalic, 37 weeks, spontaneous labor/induction) favorable candidates for vaginal delivery, and probably are the population that will get the easiest response to various initiatives. Moreover, there were significant differences between healthcare facilities, especially private hospitals. This issue is of concern because of the financial burden of unnecessary CSs on the healthcare system. Several implementations have been investigated by different publications, these are worth discussing and can be adapted to the social and demographic characteristics of each country and inserted into the system.

Ethics

Ethics Committee Approval: Not necessary.

Informed Consent: Informed consent was obtained from all participants.

Peer-review: Internally peer-reviewed.

Authorship Contributions

Concept: M.M.U., S.B., M.G.G., Design: S.B., T.A.E., Data Collection or Processing: M.M.U., T.A.E., M.G.G., Analysis or Interpretation: S.B., M.G.G., Literature Search: S.B., T.A.E., M.G.G., Writing: M.M.U., T.A.E.

Conflict of Interest: No conflict of interest was declared by the authors.

Financial Disclosure: The authors declared that this study received no financial support.