Cesarean section trends in the Nordic Countries - a comparative analysis with the Robson classification.
BACKGROUND
The cesarean rates are low but increasing in most Nordic countries. Using the Robson classification, we analyzed which obstetric groups have contributed to the changes in the cesarean rates.


METHODS
Retrospective population-based registry study including all deliveries (3 398 586) between 2000 and 2011 in Denmark, Finland, Iceland, Norway and Sweden. The Robson group distribution, cesarean rate and contribution of each Robson group were analyzed nationally for four 3-year time periods. For each country, we analyzed which groups contributed to the change in the total cesarean rate.


RESULTS
Between the first and the last time period studied, the total cesarean rates increased in Denmark (16.4 to 20.7%), Norway (14.4 to 16.5%) and Sweden (15.5 to 17.1%), but towards the end of our study, the cesarean rates stabilized or even decreased. The increase was explained mainly by increases in the absolute contribution from R5 (women with previous cesarean) and R2a (induced labor on nulliparous). In Finland, the cesarean rate decreased slightly (16.5 to 16.2%) mainly due to decrease among R5 and R6-R7 (breech presentation, nulliparous/multiparous). In Iceland, the cesarean rate decreased in all parturient groups (17.6 to 15.3%), most essentially among nulliparous women despite the increased induction rates.


CONCLUSIONS
The increased total cesarean rates in the Nordic countries are explained by increased cesarean rates among nulliparous women, and by an increased percentage of women with previous cesarean. Meanwhile, induction rates on nulliparous increased significantly, but the impact on the total cesarean rate was unclear. The Robson classification facilitates benchmarking and targeting efforts for lowering the cesarean rates.
University of Helsinki, Helsinki, Finland.|Department of Obstetrics and Gynecology, Helsinki University Hospital, Helsinki, Finland.
Aura
http://orcid.org/0000-0001-9968-6660
A
Pyykönen
National Institute for Health and Welfare THL, Helsinki, Finland.|Department of Neurobiology, Care Sciences and Society, Division of Family Medicine, Karolinska Institute, Stockholm, Sweden.
Mika
http://orcid.org/0000-0001-8254-7525
M
Gissler
University of Copenhagen, Copenhagen, Denmark.|Department of Obstetrics and Gynecology, Nordsjaelland Hospital, Hillerod, Denmark.
Ellen
E
Løkkegaard
University of Copenhagen, Copenhagen, Denmark.|Department of Obstetrics, Rigshospitalet, Copenhagen, Denmark.
Thomas
T
Bergholt
University of Copenhagen, Copenhagen, Denmark.|Department of Obstetrics, Rigshospitalet, Copenhagen, Denmark.
Steen C
SC
Rasmussen
The Icelandic Birth Registry, Akureyri, Iceland.|Institute of Health Science Research, University of Akureyri, Akureyri, Iceland.
Alexander
A
Smárason
The Icelandic Birth Registry, Akureyri, Iceland.|Institute of Health Science Research, University of Akureyri, Akureyri, Iceland.|Landspitali University Hospital, Reykajvik, Iceland.
Ragnheiður I
http://orcid.org/0000-0003-0503-1319
RI
Bjarnadóttir
Landspitali University Hospital, Reykajvik, Iceland.
Birna B
BB
Másdóttir
Swedish National Board of Health and Welfare, Stockholm, Sweden.|University of Lund, Lund, Sweden.
Karin
http://orcid.org/0000-0001-5765-2630
K
Källén
Department of Health Registries, Norwegian Institute of Public Health, Bergen, Norway.|Department of Clinical Science, University of Bergen, Bergen, Norway.
Kari
K
Klungsoyr
Department of Clinical Science, University of Bergen, Bergen, Norway.|Haukeland University Hospital, Bergen, Norway.
Susanne
S
Albrechtsen
Department of Community Medicine, Faculty of Health Sciences, UiT the Arctic University of Norway, Tromsø, Norway.
Finn E
FE
Skjeldestad
University of Helsinki, Helsinki, Finland.|Hyvinkää Hospital, Hyvinkää, Finland.
Anna-Maija
http://orcid.org/0000-0001-9352-0125
AM
Tapper
D002585:Cesarean Section / Q000706:statistics & numerical data / Q000639:trends*; D016208:Databases, Factual; D005260:Female; D006801:Humans; D007231:Infant, Newborn; D008427:Maternal Health Services / Q000706:statistics & numerical data / Q000639:trends; D011247:Pregnancy; D011256:Pregnancy Outcome; D012189:Retrospective Studies; D012537:Scandinavian and Nordic Countries / Q000453:epidemiology
Cesarean section; Robson classification; delivery; induction of labor; uterine scar