Abstract
Background:
Cesarean section is performed to save the lives of the mother and the fetus. According to the World Health Organization (WHO), the expected cesarean section rate in different countries should be 10% - 15%, which is about 72.1% in Iran.Objectives:
Therefore, due to the high prevalence of cesarean section, the present study was conducted to determine the prevalence of cesarean section based on Robson’s classification in selected hospitals of Shiraz University of Medical Sciences.Methods:
This descriptive-prospective study was conducted among 1787 women who had undergone a cesarean section in Hazrat Zeinab and Hafez hospitals of Shiraz in 2018. The data were collected by the researcher from the data recorded in the two delivery centers, and all the women were classified into 10 Robson groups. Cesarean section was calculated for each group of Robson’s classification. Data were analyzed using descriptive statistics (frequency and percentage) in SPSS, version 22.Results:
Findings showed that 63.4% of the deliveries were performed through cesarean section, and the highest frequency (46.6%) was related to group 5, followed by group 2 (19.5%).Conclusions:
Given the high Prevalence of cesarean section observed in this study, it is recommended that the rate of cesarean section should be reduced in nulliparous women (group 2), and vaginal delivery should be increased after cesarean section (group 5).Keywords
1. Background
The birth of a baby occurs through a natural mechanism called delivery, which is an automatic process without the need for intervention (1-3). Fear, anxiety, pain, and mother’s satisfaction from the previous experience of delivery play an important role in choosing the route of delivery (4, 5). Therefore, the impression of labor pain can affect the tendency and preference for the delivery route among pregnant mothers, and the increased negative perceptions regarding normal labor pain can significantly decrease the tendency toward vaginal delivery (6).
The proportion of cesarean section to the total birth rate is considered as one of the most important indicators in each country. Cesarean section is performed to save the lives of the mother and the fetus. However, today, excessive increase of cesarean section without any scientific indications has led to increased maternal and fetal morbidity and mortality (7).
In 1985, the World Health Organization (WHO) stated that the rate of cesarean section in each population should not exceed 15% (8). Cesarean section has increased worldwide from 6.7% in 1990 to 19.1% in 2014, indicating an increase of 12.4%. The rate of cesarean delivery in the developing countries has grown by 14.6% and in the developed countries by 12.7% (9). In 2012, with the growth rate of 30.3%, the United States and Australia had the highest rates of cesarean section among the developed countries. Cesarean section rate in some developing countries such as Chile (44%) Brazil, Korea, and China (46%) is alarming (10, 11).
The prevalence of cesarean section was 39.4% in northern Iran, while this rate ranged from 41.6% to 72.1% in different studies in other parts of Iran (12-17). At present, the heterogeneity in the classification of the cesarean section does not allow for valid comparisons due to the lack of clarity of the surgical indications and the relevant obstetric history. Classification of cesarean delivery should include all cesarean deliveries, have unique countermeasures, and each cesarean section should be in the same category and be used regionally, nationally, and internationally (18).
Therefore, in 2001, Robson’s classification was proposed by Robson (19), and it is the most appropriate means of measuring and comparing cesarean section to examine the reasons for changes in cesarean section trend in particular groups (20). The Robson’s classification system divides women into 10 groups based on the five parameters of the parity, onset of labor, gestational age, fetal presentation, and number of fetuses (Appendix 1 in Supplementary File).
This classification, which shows the trend of cesarean section over time, was supported by the WHO in 2014 and Federation of International of Gynecology and Obstetrics in 2016 for ease of use and flexibility (21-23). Robson’s classification is used to analyze the delivery process and effective factors in cesarean section in health care facilities of state, national and international bases in developing and developed countries (24-29).
2. Objectives
We intended to evaluate and compare the differences in cesarean rates using the Robson’s classification. Therefore, the aim of this study was to determine the prevalence of cesarean section based on Robson’s classification in Shiraz City in 2018.
3. Methods
3.1. Study Design
This descriptive-prospective study was carried out among all women who had undergone a cesarean section in Hazrat Zeinab and Hafez hospitals of Shiraz in 2018. The reason for choosing this environment was easy access to the study subjects and the availability of conditions to achieve the desired goals. The number of cesarean section cases during three months (i.e., September, October and November) was selected as the sample size. Also, census sampling was used in this study.
The inclusion criterion was women who had undergone a cesarean section, and the exclusion criterion was incomplete records. To determine the prevalence of cesarean section, we studied the hospital records and available data of all women who had undergone a cesarean section (1787 women) over three months. The researcher, after obtaining permission from the aforementioned hospitals, extracted the existing documents of cesarean section deliveries and entered the information in the table (Appendix 1 in Supplementary File).
3.2. Robeson’s Caesarian Parameters
The Robeson’s cesarean parameters contain information on the delivery of research units, including: (1) parity (nulliparous and multiparous with and without previous cesarean section); (2) the onset of labor (spontaneous onset of labor, induced labor or cesarean section before labor. Spontaneous onset of labor: women with a cervix dilatation of at least 4 centimeters enter the labor. Induced labor: the use of any pharmacological agents [prostaglandin and oxytocin] or mechanical agents [foley balloon] in women with dilatation of less than 4 cm is called labor induction. Cesarean section before labor: all women who had experienced cesarean section and had neither entered labor nor sustained labor induction) (30), (3) gestational age (preterm or term); (4) fetal presentation (cephalic, breech or transverse/oblique); and (5) the number of fetuses (singleton and multiple births). According to the above information, each research sample was entered into the Robson’s classification. Then, the total number of cesarean sections was calculated by the statistics of the total number of cesarean deliveries in these centers, and the share of each group was determined in the total amount of cesarean sections.
3.3. Statistical Analysis
Data were analyzed using descriptive statistics (i.e., frequency, mean and standard deviation) in SPSS, version 22.
3.4. Ethical Considerations
Ethics committee approval was obtained from the Research Ethics Committee of Shiraz University of Medical Sciences. Permission to conduct the research was given by the authorities of the related units, and the full explanation of the objectives of the study was provided to the authorities. The authorities were assured that all the research information was kept confidential.
4. Results
Among the 2,819 women who delivered in the target hospitals, 1032 (36.6%) women had a vaginal delivery, and 1787 (63.4%) had a cesarean delivery. Among the 1787 cases of cesarean delivery, 455 (25.5%) women had scheduled a cesarean section, and 1332 (74.5%) women had emergency cesarean section.
Of the 2819 individuals who had delivery in Shiraz hospitals, 1,686 women were referred to Hazrat Zeinab Hospital and 1133 women were referred to Hafez Hospital. In general, 60.3% of the women in Hazrat Zeinab Hospital and 68.05% in Hafez Hospital had cesarean section (Table 1).
| Name of Hospital | Mode of Delivery | Values | Total |
|---|---|---|---|
| Hazrat Zeinab | NV | 670 (39.7) | 1686 |
| CS | 1016 (60.3) | ||
| Prelabor CS | 268 (26.4) | 1016 | |
| Emergency CS | 748 (73.6) | ||
| Hafez | NV | 362 (31.95) | 1113 |
| CS | 771 (68.05) | ||
| Prelabor CS | 187 (24.3) | 771 | |
| Emergency CS | 584 (75.7) |
The mean age of the women with cesarean section was 26.4 ± 5.7 years. The highest rate of cesarean section occurred at the age group of 25 - 29 years with the educational degree of diploma (Table 2).
| Variable | Values |
|---|---|
| Maternal age | |
| < 20 | 173 (9.7) |
| 20 - 24 | 423 (23.7) |
| 25 - 29 | 824 (46.1) |
| ≥ 30 | 367 (20.5) |
| Total | 1878 (100) |
| Education | |
| < Diploma | 688 (38.5) |
| Diploma | 874 (48.9) |
| > Diploma | 225 (12.6) |
| Total | 1878 (100) |
The majority of the women with cesarean section were multiparous with cesarean section (58.6%) and had spontaneous labor (50.1%), term pregnancy (84.7%), cephalic presentation (90.7%), and singleton pregnancies (95.2%) (Table 3). The highest rate of cesarean section was in groups 5 (46.6%) and 2 (19.5%), respectively (Table 4).
Frequency Distribution of the Prevalence of Cesarean Delivery Based on Robson’s Classificationa
| Variables of Robson’s Classification | Values |
|---|---|
| Parity | |
| Nulliparous | 541 (30.3) |
| Multiparous (excluding previous CS) | 199 (11.1) |
| Multiparous with Previous CS | 1047 (58.6) |
| Total | 1787 (100) |
| Onset of labor | |
| Spontaneous | 896 (50.1) |
| Induce | 436 (24.4) |
| Cesarean section before labor | 455 (25.5) |
| Total | 1787 (100) |
| Gestational age at delivery | |
| Term | 1513 (84.7) |
| Preterm | 274 (15.3) |
| Total | 1787 (100) |
| Fetal presentation | |
| Cephalic | 1620 (90.7) |
| Breech | 161 (9) |
| Oblique/transverse | 6 (0.3) |
| Total | 1787 (100) |
| Number of fetus | |
| Singleton | 1701 (95.2) |
| Multiple | 86 (4.8) |
| Total | 1787 (100) |
| Number | Groups | Values |
|---|---|---|
| 1 | Nulliparous, singleton, cephalic, ≥ 37 weeks’ gestation, in spontaneous labor | 38 (2.1) |
| 2 | Nulliparous, singleton, cephalic, ≥ 37 weeks’ gestation, induced labor or cesarean section before labor | 348 (19.5) |
| 3 | Multiparous (excluding previous cesarean section), singleton, cephalic, ≥ 37 weeks’ gestation, in spontaneous labor | 30 (1.7) |
| 4 | Multiparous without a previous uterine scar, with singleton, cephalic pregnancy, ≥ 37 weeks’ gestation, induced or cesarean section before labor | 115 (6.4) |
| 5 | Previous cesarean section, singleton, cephalic, ≥ 37 weeks’ gestation | 833 (46.6) |
| 6 | All nulliparous with a single breech | 55 (3.1) |
| 7 | All multiparous with a single breech (including previous cesarean section) | 35 (2) |
| 8 | All multiple pregnancies (including previous cesarean section) | 84 (4.7) |
| 9 | All women with a single pregnancy in transverse or oblique lie (including those with previous cesarean section) | 6 (0.3) |
| 10 | All singleton, cephalic, < 37 weeks’ gestation pregnancies (including previous cesarean section) | 243 (13.6) |
| Total | 1787 (100) |
5. Discussion
Results of this study showed that out of the 2819 deliveries in hospitals, 63.4% of deliveries were performed through cesarean section. According to a study by Zgheib et al. (31) in Lebanon, the overall rate of cesarean section was reported 49%, where the increase in cesarean section and decrease in vaginal delivery after cesarean section were associated with an increase in cesarean section. One study by Dhakal et al. (32) in Nepal (2016 - 2017) showed that the prevalence of cesarean section was 18.8%. The results of a review study by Rafiei et al. (33) in Iran during 1999 - 2016 showed that the total number of deliveries was 197514; of them, 94807 (48%) deliveries were cesarean section.
High education level, employed mothers, and older age of mothers were the most important factors in the high Prevalence of cesarean section (33). According to the results of Badiee Aval et al.’s study (34), the overall rate of cesarean section in Khorasan Razavi in 2011 was 52%. The number of cesarean sections in non-university hospitals was significantly higher than in university hospitals. Closer supervision in academic hospitals by faculty members and performing cesarean section based on scientific indications can be an important reason for the prevention of cesarean section without indication in these centers (34).
In the present study, the rate of cesarean section n was found to increase due to the high percentage of women with a previous cesarean section. According to the statistics, it can be stated that the prevalence of cesarean section in Shiraz is increa sing and is higher than the acceptable standard proposed by the WHO (10% - 15%). In Shiraz, the frequency of cesarean section is rising every day, as it has increased by 4.8% from 2015 (58.6%) to 2018 (63.4%).
Also, in the present study, most cases of cesarean section were in groups 5 (46.6%) and 2 (19.5%). Lafitte et al.’s (35) study performed in France (2014) showed the highest number of cesarean sections in group 5 (32.1%) and group 2 (16.7%). The increase in the cesarean section in group 5 was due to the mothers’ request and doctors’ fear of uterine rupture.
According to the results of Manny-Zitle et al.’s study (2014 - 2016), groups 5 (21.24%) and 2 (13.88%) had the highest percentage of cesarean section (36). The study of Roberge et al. (37) in Quebec (2008 - 2011) showed that the highest percentage of cesarean section was in groups 5 (35%) and 2 (17.7%). In this study, 78% of women with previous cesarean section had an elective cesarean section, and consequently, cesarean section increased in group 5 (37). Results of Lafitte, Manny-Zitle et al. (36) and Roberge’s studies (37) were consistent with those of our study. The study of Nakamura-Pereira et al. (30) in Brazil (2011 - 2012) showed that the most effective groups in the total cesarean section were groups 2 (33.6%) and 5 (30.8%). Their results are contradictory to the findings of the present study, where the highest rate of cesarean section was in group 2 because it had the highest sample size (30).
The study of Zimmo et al. (38) in Palestine (2016 - 2017) showed that the highest percentage of cesarean section was in the groups 5 (42.6%) and 8 (11.6%). The result regarding group 5 is in agreement with the present results. Since many women had more than three cesarean sections in the study by Zimmo et al., the rate of cesarean section in group 5 was the highest.
Due to the high percentage of cesarean delivery and the large share of each of these groups (5 and 2) in the rate of cesarean section, these two groups are determined as the priority for the following purposes: (1) breaking the motto of “one cesarean section is equal to always cesarean section” and (2) prevention of primary cesarean section (during labor or before labor) (39).
Considering the fact that in the present study, the Prevalence of cesarean section in group 5 was the highest, it is common to recommend repeated caesareans to women with more than one previous cesarean section (20) though vaginal delivery after cesarean section has been supported as a safe option (40). However, the number of women with vaginal delivery after cesarean section has declined in recent years because of the fear of rupture of the uterus (41, 42). Some centers have been dedicated to vaginal delivery clinics after cesarean section to help women choose consciously, to assist in decision-making, and increase the number of women who choose vaginal delivery after cesarean section (43, 44).
Group 2 was the second group with the highest rate of cesarean section. The reason for the increase in cesarean section in this group was labor induction. The number of women with labor induction was increasing (19), and decrease in the rate of cesarean section in this group would affect the incidence of cesarean section in the whole group of women with vaginal delivery and diminish the number of women in group 5 in the coming years (45).
Midwifery units should consider two important issues related to labor induction:
1) The first issue is that we need evidence of labor induction (46, 47). Limiting labor induction to those who have no clear indication has a significant effect on the incidence of cesarean section, and labor induction should not be practiced routinely.
2) The second issue is that common obstetric interventions such as labor induction and the use of oxytocin may alter the normal development of labor (20). A study on singleton, cephalic, term pregnancies with spontaneous labor showed that active labor with dilation of 0 - 1.5 cm/h begins only after 6 cm dilatation and many women may spend a lot of time to achieve 6 cm dilatation (48). Many women may also have cesarean section due to lack of progression of labor when they do not go to the active phase of labor (49).
Given that one of the main reasons for cesarean section is repeated cesarean section, most women who have their first delivery in the form of cesarean section also receive cesarean section during subsequent deliveries. Accordingly, the cause of performing cesarean section for the first time should be assessed more carefully. Any mistake in this case causes the person to be forced to undergo subsequent cesarean sections; thus, it increases the incidence of repeated cesarean sections in the future. Labor induction can also be arranged with protocols and guidelines for labor management. Due to the high Prevalence of cesarean section in various studies, it is recommended that strategies such as holding training sessions on the benefits of vaginal delivery and reducing the stress of pregnant women should be implemented. By the plan midwives’ attendance during childbirth and planned delivery, the stress of women and people around them can be reduced. Thus, it is important for health care providers to understand the short- and long-term benefits of cesarean delivery and vaginal delivery, and provide appropriate opportunities for preventing excessive use of cesarean delivery, in particular, the first cesarean delivery (50).
Strengths and weaknesses of the study:
One of the strengths of the study is that it is the first study in Iran that examined the prevalence of cesarean delivery based on Robson's classification.
5.1. Limitations of the Study
The limitations of the present study included a lack of complete accuracy of the hospital records, which did not allow for the evaluation of much of the information.
Considering the findings of this study and other studies, some suggestions are made to reduce the rate of cesarean section; we hope that the authorities will take sufficient steps towards the implementation of these suggestions.
We recommend providing the necessary facilities and opportunities for mothers who have undergone a cesarean section once to initiate spontaneous labor. Natural delivery after cesarean section in the absence of a definitive indication for cesarean section is suggested. Also, it is recommended to explore the influence of health care personnel on the choice of delivery route.
To promote physiological delivery, we recommend timely admission of mothers (no hospital admission for mothers before 40 completed weeks of pregnancy and no admission in the latent phase without indication) and not performing labor induction as a routine practice.
5.2. Conclusions
Based on Robson’s classification, cesarean section in groups 5 and 2 had the highest rate. Therefore, it is imperative that the medical team highlight the short- and long-term effects of cesarean section and vaginal delivery in prenatal visits. Besides, appropriate opportunities should be provided to prevent the overuse of cesarean section, especially early cesarean section.
Acknowledgements
References
-
1.
Hoshmandi S, Dolatian M, Kamalifard M, Gojazadeh M. Comparison of Labor Pain and Factors Affecting the Pain Perception among Primiparous and Multiparous Women Referring to Women's Private and state Hospitals in Tabriz in 2010. Medical Journal of Tabriz University of Medical Sciences & Health Services. 2012;34(3).
-
2.
Sharifirad GH, Fathi Z, Tirani M, Mehaki B. Assessing of pregnant women toward vaginal delivery and cesarean section based on behavioral intention model. Ilam University of Medical Science. 2007;15(1):19-23.
-
3.
Tabrizi J, Jafarabadi MA, Farahbakhsh M, Mohammadzedeh M. Customer quality and maternity care in Tabriz urban health centers and health posts. Journal of Clinical Research & Governance. 2012;1(1):11-5.
-
4.
Bahrie M, Latifnejad R, Abdollahian E, Esmaili H. Effect of midwife’s psycologiy & physical & Educational supportive in duration of labor stages and lobor pain force. Sabzevar Uni Medl Sci J. 2004;11(1):23-4.
-
5.
Monari F, Di Mario S, Facchinetti F, Basevi V. Obstetricians’ and midwives’ attitudes toward cesarean section. Birth. 2008;35(2):129-35.
-
6.
Ateghaee M, Nauhi S. The Imagination of Natural Vaginal Delivery Pain and Caesarean Delivery Pain and the Preference for Natural Vaginal Delivery in Pregnant Women Referring to Clinics of Kerman University of Medical Sciences. Iranian Journal of Obstetrics, Gynecology and Infertility. 2012;14(7):44-50.
-
7.
Ye J, Zhang J, Mikolajczyk R, Torloni MR, Gülmezoglu AM, Betran AP. Association between rates of caesarean section and maternal and neonatal mortality in the 21st century: a worldwide population‐based ecological study with longitudinal data. BJOG: An International Journal of Obstetrics & Gynaecology. 2016;123(5):745-53.
-
8.
[No authors listed]. Appropriate technology for birth. Lancet. 1985;2(8452):436-7. [PubMed ID: 2863457].
-
9.
Dadipour S, Madani AH, Alvai A, Rozbeh N, Safari-Moradabadi A. survey of the growing trend of cesarean section in Iran and the world. Iranian Journal of Obstetrics, Gynecology and Infertility. 2016;19(27):8-17.
-
10.
Walker R, Turnbull D, Wilkinson C. Strategies to address global cesarean section rates: a review of the evidence. Birth. 2002;29(1):28-39.
-
11.
Gibbons L, Belizan JM, Lauer JA, Betran AP, Merialdi M, Althabe F. Inequities in the use of cesarean section deliveries in the world. American journal of obstetrics and gynecology. 2012;206(4):331. e1-331. e19.
-
12.
Veghari G, Rahamti R, Ebadpour M, Shamirzadi AR, Montazeri M, Hashemifard A, et al. Cesarean section and some socio-demographics related factors in the north of Iran: an epidemiologic study. International journal of advanced biotechnology and research. 2016;7(4):229-34.
-
13.
Mahmoodi M, Moghimbeigi A, Faradmal J, Ghahramani M. Detecting rates, trends and determinants of caesarean section deliveries in Iran using generalised additive mixed models. Epidemiology Biostatistics and Public Health. 2016;13(3).
-
14.
Davari M, Maracy M, Ghorashi Z, Mokhtari M. The Relationship Between Socioeconomic Status and the Prevalence of Elective Cesarean Section in Nulliparous Women in Niknafs Teaching Centre in Rafsanjan, Iran. Women's Health Bulletin. 2014;1(2).
-
15.
Khayyatian N, Nasiri S. Prevalence of cesarean section and its causes in governmental obstetric hospitals of kashan-2014. Journal of Health and Care. 2016;18(1):28-36.
-
16.
Jouhari SH, Bayati S, Kheirabadi A, Poor F, Moradi E. Cesarean Section Rate and Its Cause in Fasa in the Year 2011. Journal of Fasa University of Medical Sciences. 2014;4(3):295-300.
-
17.
Maroufizadeh S, Bagheri LN, Almasi HA, Amini P, Esmaeilzadeh A, Navid B, et al. Prevalence of cesarean section and its related factors among primiparas in Tehran Province, Iran, in 2015. Journal of isfahan medical school. 2017;35(423):303-9.
-
18.
Farine D, Shepherd D, Robson M, Gagnon R, Hudon L, Basso M, et al. Classification of caesarean sections in Canada: the modified robson criteria. Journal of Obstetrics and Gynaecology Canada. 2012;34(10):976-9.
-
19.
Robson MS. Classification of caesarean sections. Fetal and maternal medicine review. 2001;12(1):23-39.
-
20.
Tanaka K, Mahomed K. The Ten-Group Robson Classification: A Single Centre Approach Identifying Strategies to Optimise Caesarean Section Rates. Obstet Gynecol Int. 2017;2017:5648938. [PubMed ID: 28167965]. https://doi.org/10.1155/2017/5648938.
-
21.
Betran AP, Vindevoghel N, Souza JP, Guelmezoglu AM, Torloni MR. A systematic review of the Robson classification for caesarean section: what works, doesn't work and how to improve it. PloS one. 2014;9(6). e97769.
-
22.
WHO. WHO Statement on caesarean section rates. Reprod Health Matters. 2015;23(45):149-50. [PubMed ID: 26278843]. https://doi.org/10.1016/j.rhm.2015.07.007.
-
23.
FIGO Working Group On Challenges In Care Of Mothers And Infants During Labour And Delivery. Best practice advice on the 10-Group Classifcation System for cesarean deliveries. International Journal of Gynecology & Obstetrics. 2016;135(2):232-3.
-
24.
Tan JK, Tan EL, Kanagalingan D, Tan LK. Rational dissection of a high institutional cesarean section rate: An analysis using the Robson Ten Group Classification System. Journal of Obstetrics and Gynaecology Research. 2015;41(4):534-9.
-
25.
Amatya A, Paudel R, Poudyal A, Wagle RR, Singh M, Thapa S. Examining stratified cesarean section rates using Robson classification system at Tribhuvan University Teaching Hospital. Journal of Nepal Health Research Council. 2014.
-
26.
Abdel‐Aleem H, Shaaban OM, Hassanin AI, Ibraheem AA. Analysis of cesarean delivery at Assiut University Hospital using the Ten Group Classification System. International Journal of Gynecology & Obstetrics. 2013;123(2):119-23.
-
27.
Kelly S, Sprague A, Fell DB, Murphy P, Aelicks N, Guo Y, et al. Examining caesarean section rates in Canada using the Robson Classification System. J Obstet Gynaecol Canada. 2013;35(3):206-14. https://doi.org/10.1016/s1701-2163(15)30992-0.
-
28.
Brennan DJ, Robson MS, Murphy M, O'Herlihy C. Comparative analysis of international cesarean delivery rates using 10-group classification identifies significant variation in spontaneous labor. Am J Obstet Gynecol. 2009;201(3):308 e1-8. [PubMed ID: 19733283]. https://doi.org/10.1016/j.ajog.2009.06.021.
-
29.
Delbaere I, Cammu H, Martens E, Tency I, Martens G, Temmerman M. Limiting the caesarean section rate in low risk pregnancies is key to lowering the trend of increased abdominal deliveries: an observational study. BMC Pregnancy Childbirth. 2012;12:3. [PubMed ID: 22230339]. [PubMed Central ID: PMC3267690]. https://doi.org/10.1186/1471-2393-12-3.
-
30.
Nakamura-Pereira M, do Carmo Leal M, Esteves-Pereira AP, Domingues RM, Torres JA, Dias MA, et al. Use of Robson classification to assess cesarean section rate in Brazil: the role of source of payment for childbirth. Reprod Health. 2016;13(Suppl 3):128. [PubMed ID: 27766941]. [PubMed Central ID: PMC5073850]. https://doi.org/10.1186/s12978-016-0228-7.
-
31.
Zgheib SM, Kacim M, Kostev K. Prevalence of and risk factors associated with cesarean section in Lebanon - A retrospective study based on a sample of 29,270 women. Women Birth. 2017;30(6):e265-71. [PubMed ID: 28549841]. https://doi.org/10.1016/j.wombi.2017.05.003.
-
32.
Dhakal KB, Dhakal S, Bhandari S. Profile of Caesarean Section in Mid-Western Regional Hospital in Nepal. J Nepal Health Res Counc. 2018;16(1):84-8. [PubMed ID: 29717296].
-
33.
Rafiei M, Saei Ghare M, Akbari M, Kiani F, Sayehmiri F, Sayehmiri K, et al. Prevalence, causes, and complications of cesarean delivery in Iran: A systematic review and meta-analysis. Int J Reprod Biomed (Yazd). 2018;16(4):221-34. [PubMed ID: 29942930]. [PubMed Central ID: PMC6004597].
-
34.
Badiee Aval S, Ravanshad Y, Azarfar A. Evaluation of cesarean delivery and its causes in hospitals affiliated to Mashhad University of Medical Sciences in 2011. Iranian Journal of Obstetrics, Gynecology and Infertility. 2013;16(66):10-7.
-
35.
Lafitte AS, Dolley P, Le Coutour X, Benoist G, Prime L, Thibon P, et al. Rate of caesarean sections according to the Robson classification: Analysis in a French perinatal network - Interest and limitations of the French medico-administrative data (PMSI). J Gynecol Obstet Hum Reprod. 2018;47(2):39-44. [PubMed ID: 29208502]. https://doi.org/10.1016/j.jogoh.2017.11.012.
-
36.
Manny-Zitle AI, Tovar-Rodríguez JM. Incidence of cesarean section according to Robson’s classification in the Department of Gynecology and Obstetrics of the General Hospital Dr. Fernando Quiroz Gutiérrez, ISSSTE. Cirugía y Cirujanos. 2018;86(3):261-9.
-
37.
Roberge S, Dubé E, Blouin S, Chaillet N. Reporting caesarean delivery in quebec using the robson classification system. Journal of Obstetrics and Gynaecology Canada. 2017;39(3):152-6.
-
38.
Zimmo MW, Laine K, Hassan S, Bottcher B, Fosse E, Ali-Masri H, et al. Caesarean section in Palestine using the Robson Ten Group Classification System: a population-based birth cohort study. BMJ open. 2018;8(10). e022875.
-
39.
Bolognani CV, Reis LBDSM, Dias A, Calderon IDMP. Robson 10-groups classification system to access C-section in two public hospitals of the Federal District/Brazil. PloS one. 2018;13(2). e0192997.
-
40.
Society of Obstetricians Gynaecologists of Canada clinical practice guidelines. Guidelines for vaginal birth after previous caesarean birth. Number 155 (Replaces guideline Number 147), February 2005. International journal of gynaecology and obstetrics: the official organ of the International Federation of Gynaecology and Obstetrics. 2005;89(3):319-31.
-
41.
Grobman WA, Lai Y, Landon MB, Spong CY, Rouse DJ, Varner MW, et al. The change in the VBAC rate: an epidemiologic analysis. Paediatric and perinatal epidemiology. 2011;25(1):37-43.
-
42.
Yeh J, Wactawski-Wende J, Shelton JA, Reschke J. Temporal trends in the rates of trial of labor in low-risk pregnancies and their impact on the rates and success of vaginal birth after cesarean delivery. Am J Obstet Gynecol. 2006;194(1):144. [PubMed ID: 16389024]. https://doi.org/10.1016/j.ajog.2005.06.079.
-
43.
Montgomery AA, Emmett CL, Fahey T, Jones C, Ricketts I, Patel RR, et al. Two decision aids for mode of delivery among women with previous caesarean section: randomised controlled trial. Bmj. 2007;334(7607):1305.
-
44.
Gardner K, Henry A, Thou S, Davis G, Miller T. Improving VBAC rates: the combined impact of two management strategies. Aust N Z J Obstet Gynaecol. 2014;54(4):327-32. [PubMed ID: 25117188]. https://doi.org/10.1111/ajo.12229.
-
45.
Le Ray C, Prunet C, Deneux-Tharaux C, Goffinet F, Blondel B. [Robson classification: A tool for assessment of caesarean practices in France]. J Gynecol Obstet Biol Reprod (Paris). 2015;44(7):605-13.
-
46.
Leduc D, Biringer A, Lee L, Dy J, Corbett T, Duperron L, et al. Induction of labour. Journal of Obstetrics and Gynaecology Canada. 2013;35(9):840-57.
-
47.
Lydon-Rochelle MT, Cárdenas V, Nelson JC, Holt VL, Gardella C, Easterling TR. Induction of labor in the absence of standard medical indications: incidence and correlates. Medical care. 2007;45(6):505-12.
-
48.
Zhang J, Troendle JF, Yancey MK. Reassessing the labor curve in nulliparous women. American journal of obstetrics and gynecology. 2002;187(4):824-8.
-
49.
Zhang J, Landy HJ, Branch DW, Burkman R, Haberman S, Gregory KD, et al. Contemporary patterns of spontaneous labor with normal neonatal outcomes. Obstetrics and gynecology. 2010;116(6):1281.
-
50.
Caughey AB, Cahill AG, Guise J, Rouse DJ, American College of Obstetricians, Gynecologists. Safe prevention of the primary cesarean delivery. American journal of obstetrics and gynecology. 2014;210(3):179-93.