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\begin{document}

\title{The Project Appropriate Birth: significance of the Robson classification
in confronting the caesarean section ``pandemic''}



\author[1]{Nikolaos Vrachnis}%
\affil[1]{National and Kapodistrian University of Athens}%


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  \date{May 03, 2024}


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Mini commentary on BJOG-21-0235.R1

\textbf{The Project Appropriate Birth: significance of the Robson
classification in confronting the caesarean section}

\textbf{``pandemic''}

N. Vrachnis,\textsuperscript{a,b}

\textsuperscript{a} Third Department of Obstetrics and Gynaecology,
National and Kapodistrian University of Athens Medical School, Attikon
Hospital, Athens, Greece

\textsuperscript{b} Vascular Biology, Molecular and Clinical Sciences
Research Institute, St George's University of London, London, UK

Worldwide, caesarean section rates have soared over the last 30 years,
and the WHO has recommended the Robson classification system as a global
standard for assessment, monitoring, and comparison of caesarean section
rates: however, it not yet widely used in daily practice in certain
countries, with many reporting extremely high rates of caesarean
sections. This reduction is expected to lead to further improvement in
maternal and neonatal morbidity (Vrachnis et al. Int J Gynaecol Obstet
2011;115(1):16-9).

The article by Ferreira D'Agostini Marin et al. (BJOG-21-0235.R1) shows
a significant reduction of caesarean section rates after implementation
of interventions based on the Robson 10-group classification system.
This is a well-designed before/after study, incorporating a significant
number of deliveries in Brazil. The researchers found that the main
contributors to caesarean section rates were group 5 and group 2, thus
pinpointing those groups on whom future interventions should focus. It
would also be of great interest to see the impact of this intervention
on caesarean section rates in the Project Appropriate Birth (PPA) in
more maternity hospitals in Brazil.

The reasons for a high caesarean section rate may differ between
countries; however, the complications are likely to be the same. The
explanation for the increased rate of caesarean section is complex, as
it is the result of multiple factors (Gregory et al. Am J Perinatol
2012;29(1):7-18). The indications for caesarean section are clearly
defined by scientific societies and organisations and should not be
disregarded or misinterpreted in practice. At the same time, special
characteristics of obstetric practice nowadays should not be ignored
either as they explain the increased rates of caesarean section, such as
the significantly higher age of pregnant women compared to the past, a
result both of advances in IVF as well as of the modern way of life.
Inevitably, the possibility of pathology coexistence as a medical
indication for caesarean section has increased.

Further interventions are evaluated in the ENGAGE (ENhancinG vAGinal
dElivery) Trial (ClinicalTrias.gov: NCT04504500, which is a prospective
study that started in June 2021 in Greece. It is a nationwide trial that
develops 10 interventions in a stepped-wedge clinical trial aiming to
reduce caesarean section rates and systematically investigate the causes
of Greece's high caesarean section rate. It involves 22 Greek maternity
units, the health care providers from most Greek regions, and both
public and private hospitals, with different facilities, aiming at a
highly representative sample. Secondary outcomes studied are maternal
and neonatal morbidity and mortality.

An integrated approach is needed to address the problem. Nevertheless,
the current increase perpetuates itself through a vicious cycle; the
education of health care providers should be improved along with public
awareness. Health care providers should also be encouraged to avoid
practising ''defensive medicine'' due to litigation risks. The relevant
authorities of each country should also assume their share of the
responsibility, understaffing of the Public Health Systems
(obstetricians, midwives, and anaesthesiologists) in certain countries
impacting caesarean section rates. Further long-term studies are
essential to scrutinize the underlying issues and develop more effective
strategies to reduce caesarean section rates.

Disclosure of interests. None declared.

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