title: Use of the Robson classification to assess caesarean section trends in 21 countries: a secondary analysis of two WHO multicountry surveys.
abstract: BACKGROUND
  Rates of caesarean section surgery are rising worldwide, but the determinants of this increase, especially in low-income and middle-income countries, are controversial. In this study, we aimed to analyse the contribution of specific obstetric populations to changes in caesarean section rates, by using the Robson classification in two WHO multicountry surveys of deliveries in health-care facilities. The Robson system classifies all deliveries into one of ten groups on the basis of five parameters: obstetric history, onset of labour, fetal lie, number of neonates, and gestational age.
  
  
  METHODS
  We studied deliveries in 287 facilities in 21 countries that were included in both the WHO Global Survey of Maternal and Perinatal Health (WHOGS; 2004-08) and the WHO Multi-Country Survey of Maternal and Newborn Health (WHOMCS; 2010-11). We used the data from these surveys to establish the average annual percentage change (AAPC) in caesarean section rates per country. Countries were stratified according to Human Development Index (HDI) group (very high/high, medium, or low) and the Robson criteria were applied to both datasets. We report the relative size of each Robson group, the caesarean section rate in each Robson group, and the absolute and relative contributions made by each to the overall caesarean section rate.
  
  
  RESULTS
  The caesarean section rate increased overall between the two surveys (from 26.4% in the WHOGS to 31.2% in the WHOMCS, p=0.003) and in all countries except Japan. Use of obstetric interventions (induction, prelabour caesarean section, and overall caesarean section) increased over time. Caesarean section rates increased across most Robson groups in all HDI categories. Use of induction and prelabour caesarean section increased in very high/high and low HDI countries, and the caesarean section rate after induction in multiparous women increased significantly across all HDI groups. The proportion of women who had previously had a caesarean section increased in moderate and low HDI countries, as did the caesarean section rate in these women.
  
  
  CONCLUSIONS
  Use of the Robson criteria allows standardised comparisons of data across countries and timepoints and identifies the subpopulations driving changes in caesarean section rates. Women who have previously had a caesarean section are an increasingly important determinant of overall caesarean section rates in countries with a moderate or low HDI. Strategies to reduce the frequency of the procedure should include avoidance of medically unnecessary primary caesarean section. Improved case selection for induction and prelabour caesarean section could also reduce caesarean section rates.
  
  
  BACKGROUND
  None.
authors: School of Population Health, Faculty of Medicine, Dentistry and Health Sciences, University of Western Australia, 35 Stirling Highway, Crawley, WA, Australia; UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction, Department of Reproductive Health and Research, World Health Organization, Geneva, Switzerland. Electronic address: vogeljo@who.int.
authors: Joshua P
authors: JP
authors: Vogel
authors: UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction, Department of Reproductive Health and Research, World Health Organization, Geneva, Switzerland.
authors: Ana Pilar
authors: AP
authors: Betrán
authors: Calgary Foothills Primary Care Network, Alberta Health, Calgary, AB, Canada.
authors: Nadia
authors: N
authors: Vindevoghel
authors: Department of Social Medicine, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil; GLIDE Technical Cooperation and Research, Ribeirão Preto, São Paulo, Brazil.
authors: João Paulo
authors: JP
authors: Souza
authors: Department of Obstetrics, São Paulo Federal University, São Paulo, Brazil; Brazilian Cochrane Centre, São Paulo, Brazil.
authors: Maria Regina
authors: MR
authors: Torloni
authors: Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.
authors: Jun
authors: J
authors: Zhang
authors: UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction, Department of Reproductive Health and Research, World Health Organization, Geneva, Switzerland.
authors: Özge
authors: Ö
authors: Tunçalp
authors: Department of Health Policy, National Center for Child Health and Development, Tokyo, Japan.
authors: Rintaro
authors: R
authors: Mori
authors: Department of Health Policy, National Center for Child Health and Development, Tokyo, Japan; Department of Pediatrics, Graduate School of Medicine, University of Tokyo, Tokyo, Japan.
authors: Naho
authors: N
authors: Morisaki
authors: National Institute of Public Health, Cuernavaca, Mexico.
authors: Eduardo
authors: E
authors: Ortiz-Panozo
authors: Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA.
authors: Bernardo
authors: B
authors: Hernandez
authors: Social Protection and Health Division, Inter-American Development Bank, Mexico City, Mexico.
authors: Ricardo
authors: R
authors: Pérez-Cuevas
authors: Department of Obstetrics and Gynaecology, School of Medicine, College of Health Science, University of Nairobi, Nairobi, Kenya.
authors: Zahida
authors: Z
authors: Qureshi
authors: UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction, Department of Reproductive Health and Research, World Health Organization, Geneva, Switzerland.
authors: A Metin
authors: AM
authors: Gülmezoglu
authors: UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction, Department of Reproductive Health and Research, World Health Organization, Geneva, Switzerland.
authors: Marleen
authors: M
authors: Temmerman
mesh_terms: D000328:Adult; D002585:Cesarean Section / Q000639:trends*; D003906:Developing Countries / Q000706:statistics & numerical data*; D005260:Female; D005865:Gestational Age; D019538:Health Care Surveys; D006801:Humans; D011247:Pregnancy; D014944:World Health Organization