title: Is the Robson's classification system burdened by obstetric pathologies, maternal characteristics and assistential levels in comparing hospitals cesarean rates? A regional analysis of class 1 and 3.
abstract: OBJECTIVE
  To assess if maternal risk profile and Hospital assistential levels were able to influence the inter-Hospitals comparison in the class 1 and 3 of the "The Ten Group Classification System" (TGCS).
  
  
  METHODS
  A population-based analysis using data from Institutional data-base of an Italian Region was carried out. The 11 maternity wards were divided into two categories: second-level hospitals (SLH), and first-level hospitals (FLH). The recorded deliveries were classified according to the TGCS. To analyze if different maternal characteristics and the hospitals assistential level could influence the cesarean section (CS) risk, a multivariate analysis was done considering separately women in the TGCS class 1 and 3.
  
  
  RESULTS
  From January 2011 to December 2013 were recorded 19,987 deliveries. Of those 7,693 were in the TGCS class 1 and 4,919 in the class 3. The CS rates were 20.8% and 14.7% in class 1 (p < 0.0001) and 6.9% and 5.3% (p < 0.0230) in class 3, respectively in the FLH and SLH. The multivariate logistic regression showed that the FLH, older maternal age and gestational diabetes were independent risk factors for CS in groups 1 and 3. Obesity and gestational hypertension were also independent risk factors for group 1.
  
  
  CONCLUSIONS
  TGCS is a useful tool to analyze the incidence of CS in a single center but in comparing different Hospitals, maternal characteristics and different assistential levels should be considered as potential bias.
authors.affiliation: a Department of Obstetrics and Gynecology , University of Perugia , S. Andrea delle Fratte , Perugia , Italy.
authors.forename: Sandro
authors.initials: S
authors.lastname: Gerli
authors.affiliation: a Department of Obstetrics and Gynecology , University of Perugia , S. Andrea delle Fratte , Perugia , Italy.
authors.forename: Alessandro
authors.initials: A
authors.lastname: Favilli
authors.affiliation: b S.C.A.R.L , Umbria Digitale , Perugia , Italy.
authors.forename: David
authors.initials: D
authors.lastname: Franchini
authors.affiliation: b S.C.A.R.L , Umbria Digitale , Perugia , Italy.
authors.forename: Marcello
authors.initials: M
authors.lastname: De Giorgi
authors.affiliation: c Regione Umbria , Direzione Regionale Salute , Perugia , Italy.
authors.forename: Paola
authors.initials: P
authors.lastname: Casucci
authors.affiliation: d Dipartimento Materno Infantile, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico , Università di Milano , Milan , Italy.|e Dipartimento di Scienze Cliniche e di Comunità , Universita' di Milano , Milan , Italy.
authors.forename: Fabio
authors.initials: F
authors.lastname: Parazzini
mesh_terms: D002585:Cesarean Section / Q000706:statistics & numerical data*; D036861:Delivery, Obstetric / Q000145:classification*; D005260:Female; D006761:Hospitals / Q000706:statistics & numerical data*; D006801:Humans; D008423:Maternal Age; D016017:Odds Ratio; D011247:Pregnancy; D011248:Pregnancy Complications / Q000453:epidemiology*
keywords: Cesarean section; Robson classification; TGCS; advanced maternal age; hospital assistential level