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Abstract
Background Caesarean section (CS) is an important indicator of access to and quality of maternal health services. The WHO recommends the Robson 10-group classification system as a global standard for assessing, monitoring and comparing CS rates at all levels. Identification of the Robson groups that contribute the most to the overall CS is important to determine possible modifiable factors in our attempts to reduce the CS rate. This study was designed to analyse CS deliveries performed in a tertiary referral centre in Somalia according to the Robson 10-group classification system.
Design This retrospective study included data on consecutive mothers who had deliveries from 1 January 2022 to 1 July 2023.
Methods Data were categorised according to the Robson classification. Each patient’s data was coded according to Robson’s specifications.
Results A total of 3030 deliveries were analysed. Of these, 1156 (38.2 %) were CS. Among the five largest Robson groups, the highest absolute contribution to CSs was found in group 5, with 11.4% followed by group 10 with a corresponding contribution of 9.4%. In the next three largest Robson groups (groups 1, 3, 4), the absolute contributions were 3.9%, 3.4% and 3.3%, respectively. The total percentages of CSs among all deliveries (n=3030) and among all CSs (n=1156) in the five largest Robson groups were 31.3% and 82.2%, respectively.
Conclusion Our analysis showed that the overall caesarean section rate was 38.2%, and those major contributors were Robson groups 5 and 10.
- Reproductive medicine
- Minimally invasive surgery
- Urogynaecology
Data availability statement
Data are available upon reasonable request.
This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
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STRENGTHS AND LIMITATIONS OF THIS STUDY
The combination of two different periods of 2022 and 2023 enlarged the sample size and allowed us to avoid seasonal bias.
A single-hospital study might be less generalisable, but our conclusions are relevant and applicable in other contexts.
The main limitation of our study was its retrospective nature.
The second main limitation of our study is that the fetal viability cut-off value in Somalia is higher than the gestational age thresholds (≥28 weeks) reported in developed countries.
Introduction
In 2015 and 2021, the WHO proposed adopting the Robson classification system, developed by Michael Robson in 2001, for assessing, monitoring and comparing caesarean section (CS) rates over time and between different institutions, regions and countries.1 2 The Robson system includes specific obstetric variables: parity, previous CS, onset of labour, number of fetuses, gestational age and fetal presentation, hence the 10 Robson groups.3 In the 2021 update, although the WHO does not recommend a specific CS rate for countries to achieve at the population level, it is emphasised that CS rates up to 10% are highly associated with reductions in maternal and newborn mortality rates. In contrast, CS rates exceeding 10% have been shown to have no benefit in decreased maternal and newborn mortality and may cast doubt on the actual necessity of CSs.1
In Robson classification, each Robson group represents a cohort of women with similar obstetric characteristics. CS rates higher than those given in the Robson system may indicate problems in the management of pregnant women and their deliveries, resulting from obstetric policies, the training and experience of obstetricians and the education and awareness of pregnant women.4
There have been a considerable number of studies aiming to reflect CS rates in individual healthcare facilities.5–7 These reports have mainly come from countries with well-established healthcare systems, which is not the case for sub-Saharan African countries and other low-income countries.8
This study was designed to analyse CS deliveries performed in a tertiary referral centre in Somalia according to the Robson 10-group classification system.
Methods
Study design and participants
This retrospective study evaluated included 3097 consecutive mothers who had deliveries from 1 January 2022 to 1 July 2023, at the Department of Obstetrics of Mogadishu Somali Turkey Training and Research Hospital in Mogadishu, the capital city of Somalia. It is a dedicated centre particularly for high-risk and referred cases. Analysis and reporting of the results are in compliance with the Strengthening the Reporting of Observational Studies in Epidemiology checklist.
Data collection
Data on pregnant women were manually retrieved from admission-to-discharge electronic hospital records and delivery registries by the authors and manually transferred to spreadsheets. Finally, all data and spreadsheets were independently checked by two obstetricians. In addition to maternal age and a detailed inquiry into the past obstetric history of each participant, including parity and previous CS, particular attention was given to delivery-specific information concerning parity (nulliparity or multiparity), onset of labour (spontaneous, induced or CS before labour), fetal presentation/lie (cephalic, breech, transverse or oblique), number of fetuses (single or multiple), mode of delivery (vaginal or CS) and gestational age (GA) (term or preterm). Neonatal data included stillbirths, APGAR score, birth weight and the need for admission to the neonatal intensive care unit (NICU).
All women underwent an ultrasound examination at admission. Gestational age was calculated from the last menstrual period in combination with an obstetric ultrasound examination performed until 20 weeks of pregnancy. In case of an unknown last menstrual period or no early ultrasound, GA was estimated based on admission ultrasound examination. In addition to an ultrasound examination at admission, birth weights <2500 g and ≥2500 g were considered in favour of preterm and term deliveries, respectively. In case of inconsistency between ultrasound examination and birth weight, the decision for a term or preterm delivery was based on the birth weight. This strategy has been employed in other studies conducted in similar settings.5 9 10
Inclusion criteria were at least 28 weeks of gestation and a birth weight of at least 1000 g. Women were excluded in the presence of any of the following: uterine rupture, any traumatic wound that could affect delivery (GA <28 weeks), birth weight (<1000 g) and incomplete clinical or hospital data.
Patients and public involvement
There was no patient or public involvement in planning or executing this study because of the retrospective study. There are no plans to disperse the results of our research to study participants or the applicable patient community. However, results are being disseminated among the professional communities of Somali and to policymakers, with the intent to inform future health policy decisions.
Caesarean section rate based on Robson criteria
Data were categorised according to the Robson classification report table as designed by seven columns: column 1 indicating the type of the group; column 2 number of CS in group; column 3 number of women in group; column 4 group size (%); column 5 group CS rate (%); column 6 absolute group contribution to overall CS rate (%); and column 7 relative contribution of the group to overall CS rate (%). The absolute contribution was defined as the percentage of the number of CSs in each group divided by the total number of women delivered in the hospital during the study period. The relative contribution was defined as the percentage of the number of CSs in each group divided by the total number of CSs performed in the hospital during the study period.3
Data processing and analysis
Data were processed using the Statistical Package for Social Sciences (SPSS) V.29 (IBM Corp., Armonk, New York, USA). Continuous data were expressed as means, SD, median, minimum and maximum and categorical data as frequencies and percentages. Each patient’s data were coded according to the Robson specifications and after computing group variables.
Results
Sociodemographic and obstetric characteristics
During the study period, 3097 women were admitted for delivery, of whom 3030 were eligible for the analysis. A total of 67 women were excluded from the study. Six mothers had uterine rupture, and one mother had gunshot-induced CS. Data from 60 women were incomplete. The characteristics of the participants are summarised in table 1. The mean age was 26.5±5.6 years (range 15–47). The median parity was 3 (range 1–15). A total of 2966 single and 64 multiple (63 twins and 1 triplet) deliveries occurred at a mean of 37.7±3.1 weeks (range 28–42). Of 3030 women, 1874 (61.9%) had normal vaginal delivery and 1156 (38.2%) had CS.
Clinical and obstetrics characteristics of the participants (n=3030)
The mean birth weight was 2959±743 g. A total of 550 women had no early ultrasound examination or could not remember their last menstrual period; therefore, GA was estimated based on ultrasound examination and birth weight or on the latter when there was inconsistency between the two.
During the 18 months of the study, the first five largest patient groups in descending order were seen in Robson groups 3, 10, 1, 5 and 4. The largest number of deliveries (n=1188, 39.2%) was recorded in group 3. The next largest number (n=632, 20.9%) was recorded for group 10, followed by group 1 with 477 deliveries (15.7%), group 5 with 351 deliveries (11.6%) and group 4 with 122 deliveries (4.0%). In these five Robson groups (groups 3, 10, 1, 5 and 4), CS rates were 8.7% (103/1188), 45.1% (285/632), 24.5% (117/477), 98.0% (344/351) and 82.8% (101/122), respectively (table 2).
Distribution of the Robson groups with their contributions to the overall CS rate*
Among these five groups, group 5 had the highest absolute (11.4%) and relative (29.8%) contributions to CSs, followed by corresponding contributions in descending order by 9.4% and 24.7% in group 10, 3.9% and 10.1% in group 1, 3.4% and 8.9% in group 3 and 3.3% and 8.7% in group 4 (table 2).
Among all deliveries (n=3030) and among all CSs (n=1156), CSs accounted for 31.3% and 82.2%, respectively, in the five largest Robson groups (table 2).
Discussion
Considering the Robson classification system, with CS rates of considerable sample size (n=3030) and a long period of enrolment (18 months), the current study represents the first comprehensive report from one of the most specialised hospitals in Somalia delivering healthcare to high-risk patients, particularly with services to pregnant women and newborns.
The Robson classification was developed and has been proposed to be used as a tool to monitor and compare CS rates in the same setting over time and between different settings. Given the progressive increase in CS rates worldwide, the WHO considers this trend a major public health concern bringing about potential maternal and perinatal risks, inequity in access and cost issues.3
Our findings show that, during an 18-month period, a total of 3030 women delivered, for which 1156 CSs were performed. Based on the Robson classification, group 3, which comprised the largest number of women (n=1188, 39.2% of the study population), contributed only 8.5% to the overall rate of CS (relative contribution). In comparison with reports from developed countries,11–13 the size of group 3 was considerably larger, which is consistent with the social characteristics of Somalia where women have more than one child. However, the relative contribution of group 3 to CSs was greater than reports from developed countries, mainly because of the hospital’s referral status for high-risk pregnancies (severe pre-eclampsia, vasa previa and intrauterine growth retardation, etc.). In accordance with the manual on Robson classification, it would be reasonable to assess group 3 together with group 4 because of similarities in the characteristics of the two groups (multiparous, single cephalic, ≥37 weeks and no previous CS) except for the type of labour onset (spontaneous vs induced or CS).3 Despite being the fifth largest group, the size of group 4 was 4.0%, with a relative contribution to CS of 8.7%. The sum of the two group sizes was 43.2%, which is greater than 30% proposed by the Robson implementation manual for countries where women usually have their first child. The Robson implementation manual states that for women with more than one child, this sum may exceed 30.0%,3 which is just the case for Somali women. Among reproductive women in this cohort, the rate of multiparity was 72%, accounting for the higher rate for the sum of the two groups.
In group 10, which had the second largest size with 20.9%, the relative contribution of the group was 24.7%. This group size was considerably greater than 5% reported by the manual for normal risk settings, as well as by studies from Germany (12.2%)11 and Ethiopia (15.9%).5 This finding has main implications: a fifth of reproductive Somali women have the problem of preterm deliveries which also pose other challenges such as fetal growth restriction or pre-eclampsia and other pregnancy or medical complications. As a corollary, 45.1% of women having these problems underwent CS in this group, accounting for nearly a quarter of all CSs performed in this cohort. This also indicates the crucial importance of Turkey Hospital in the capital city of Somalia serving Somali women as a tertiary referral centre with highly dedicated healthcare professionals and a sophisticated obstetric clinic and NICU.
In our analysis, the CS rates in group 1 and group 2 were considerably higher at 24.5% and 85.1%, respectively, as compared with the original manual recommendation of 9.8% and 39.9%, respectively, and other reports in the literature.5 11–13 This discrepancy mainly resulted from the higher number of women who had been referred to our centre with a diagnosis of severe pre-eclampsia. This phenomenon is a unique problem in underdeveloped countries like Somalia, where access to prenatal monitoring is extremely restricted because of limited sources and the low level of education. Another feature that distinguishes Somalia from many countries is that pregnant women are free by law to choose CS either before or after initiation of spontaneous labour. These two factors might be influential in making group 1 the third and group 2 the sixth significant contributors to the overall CS rate.
In group 5, we found the second highest CS rate at 98.0% following group 9 (100.0%). This is reasonable because this group involves pregnancies following previous CS where subsequent CS is almost inevitable. There appear to be two ways to decrease the CS rate in this group. As the necessity for CS primarily arises from a previous CS, the CS rate in group 5 cannot be reduced unless CS rates are lowered in the preceding groups. Second, the routine practice in obstetrics unfortunately is adopting a CS strategy following a previous CS, despite the presence of a universal consensus about the safety of and thus the necessity for a subsequent vaginal delivery in eligible women following a single previous lower segment CS. Therefore, attempting vaginal delivery in this setting would decrease the CS rate in group 5.
Considering the steps recommended by the Robson classification to assess the type of population, we derived the following conclusions: For step 1, the sum of group 1 and group 2 was 591, yielding a percentage of 19.5%, being considerably lower than the ideal percentage of 38.1%. This discrepancy arises from the unique characteristics of Somalia and other low- and middle-income countries where most of the population is represented by multiparous women, reducing the total size of group 1 and group 2. Therefore, higher percentages reported from some African countries with similar characteristics to those of Somalia may cast doubt about their reliability.14 15 Our finding was consistent with a report from Eastern Ethiopia.16 For step 2, the sum of group 3 and group 4 (n=1310) corresponded to 43.2%. The proportion of multiparous women in Somalia now exerts a positive effect on this result. Group sizes for this step do not differ much across African countries.14–16 As for step 3, the proportion of the size of group 5 to the total CS rate was 30%, indicating a higher total CS rate in Somalia. The reported rates are 35.2% and 32.8 for Tanzania15 and Ethiopia,16 respectively.
One limitation to this study is that we defined fetal viability with higher thresholds for gestational age (≥28 weeks) and birth weight (≥1000 g) compared with those reported for developed countries. In the presence of a gestational age of less than 28 weeks and a birth weight of less than 1000 g, the likelihood of a newborn to survive is considerably low due to limited healthcare settings in Somalia.
Conclusions
Our analysis identified the contribution of each group to the CS rate in each category of the Robson classification system in a tertiary healthcare centre in Somalia. The overall CS rate was 38.2%; those major contributors were Robson groups 5 and 10. This study also revealed the next three largest contributors to the CS rate among low-risk groups (Robson groups 1, 3 and 4). A detailed analysis of target groups is essential to identify modifiable factors and implement interventions to reduce CS rates. Health authorities should adopt Robson’s 10-group classification system as a standardised audit tool in all Somali hospitals. This may enable CS rate monitoring, inter-hospital comparisons and the identification of practice gaps while supporting strategies to reduce unnecessary CS.
Data availability statement
Data are available upon reasonable request.
Ethics statements
Patient consent for publication
Ethics approval
The study was approved by the Mogadishu Somali Turkey Training and Research Hospital Institutional Review Board (IRB) (Permission number: MSTH/15148/22.08.2023/827). Obtaining inform consent was waived by the IRB due to the retrospective design of the study. The study was performed in accordance with the principles and guidelines of the Declaration of Helsinki.
Acknowledgments
We would like to thank Somali women for their participation in this study.
Footnotes
Contributors AB: conceptualisation, manuscript writing, manuscript editing and review, data collection and data analysis. HBH: manuscript writing, manuscript editing and review, and data analysis. UE: manuscript editing and review and data collection. AB acted as the guarantor for this study and accepts full responsibility for the finished work and the conduct of the study, had access to the data and controlled the decision to publish.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
Provenance and peer review Not commissioned; externally peer reviewed.