Cesarean Sections according to the Robson’s Classification in Two University Hospitals of Yaoundé: Indications and Maternofetal Outcome ()
1. Introduction
Cesarean section is one of the most commonly performed surgical procedures in obstetrics. Since about 30 years, the WHO considered 10% to 15% as the ideal rate for cesarean sections [1] . Since then, delivery by cesarean section has been increasingly performed in both developed and developing countries [2] . Higher rates have not been associated with a reduction of maternal and neonatal morbi-mortality [3] . In the last decade, the rate of cesarean sections has greatly increased worldwide; as high as above 30% in certain regions [4] . For instance, in Great Britain and Scotland, the cesarean section rate increased from 16% in 1995 to 21.5% in 2000 [5] . The National Center for Health Statistics reported that the cesarean section rate in the United States increased from 20.7% in 1996 to 32.2% in 2014 [6] . The rates rose to 24.6% in the United Kingdom in 2008-2009 and to 20.8% in France in 2010 [7] . In Cameroon, a study carried out by Kemfang et al. on early maternal complications of cesarean section: about 460 cases in two university hospitals in Yaoundé found a cesarean section rate of 19.7% in the entire population [8] . When medically justified, a cesarean section can efficiently prevent maternal and perinatal morbidity and mortality [9] . However, no data has demonstrated the advantage for the mother or for the newborn of a cesarean section without indication [10] . Like any surgical intervention, cesarean section is associated with short as well as long term risks which can last for several years after delivery and affect the health of the woman and the child as well as the future pregnancies [11] . Till date, to the best of our knowledge, there exists no classification of cesarean section published in the literature on the topic. The Robson’s classification had been widely used in several countries during the past years [12] . The WHO proposes to use the Robson’s classification like an international reference for the evaluation, the monitoring and the comparison of the rates of cesarean sections within health facilities with time and amongst them. The objectives of this study were to use the Robson’s classification to identify the groups of women having had abnormally high rates of cesarean sections and to determine the early maternofetal outcome amongst these groups.
2. Materials and Methods
Ethical considerations: The study was carried out using the fundamental principles of research according to the Helsinki declaration. Ethical clearance was obtained from the Institutional committee of Ethics and Research of the faculty of Medicine and Biomedical sciences of the University of Yaoundé 1, while research authorizations were obtained from the administrations of the Yaoundé Central Hospital (YCH) and that of Centre Hospitalier de Recherche et d’Applicationen Chirurgie Endoscopiqueet Reproduction Humaine (CHRACERH). We included the files of all women who delivered by cesarean section during the study period.
We carried out a descriptive cross-sectional study with a retrospective data collection. It went from December 2017 to May 2018. The sampling was exhaustive. We included all women having delivered during a two years’ period spanning from January 2016 to December 2017 in the both health facilities.
Data was collected using an anonymous and pretested questionnaire which was designed by the research team. The variables studied were; the age, parity, mode of labor onset, indication of the cesarean section, delivery mode, indication of the cesarean section, the occurrence or not of maternal or fetal complications. The data collected was registered and analyzed. Data codification, entry and analysis were done using the softwares CS Pro 7.0 and S.P.S.S 25.0. Tables were drawn using the software Microsoft Office Excel 2016. The Robson group of each parturient was determined using the Robson classification according to Table 1 [13] . Descriptive parameters like mean and proportion were used. The association between variables and Robson’s groups were searched using the Chi2 method, and a p value < 0.05 and a confidence interval at 95% were considered statistically significant after logistic regression.
3. Results
At the end of the study, 3578 files had been analyzed. In CHRACERH, 330 deliveries were carried out during the study period amongst which 90 underwent cesarean sections, a rate of 27.2%. At the YCH, 1863 deliveries were carried out, amongst which 462 were by cesarean section. Hence, the rates of cesarean sections were 27.2% in CHRACERH and 24.8% at YCH. The patients were statistically of a higher educational level in CHRACERH than at YCH.
The women in groups 5, 3 and 1 had the highest rates of cesarean sections in CHRACERH with 31.1%, 20.0% and 15.6% respectively. The groups 3, 1 and 5
had the highest rates of cesarean section at YCH with 22.5%, 21.6% and 17.3% respectively (Table 2 and Table 3).
At CHRACERH, most of the cesarean sections of group 1 were indicated for acute fetal distress (28.6%). Cephalopelvic disproportion was the most frequent indication of cesarean sections in group 1 at YCH (36.7%) (Table 4).
Cephalopelvic disproportion was the most frequent indication of cesarean sections in group 3 in CHRACERH and at YCH with respective frequencies of 44.4% and 39.2%. There was no statistically significant difference (p > 0.05) in the indications of cesarean sections between groups 3 of CHRACERH and of YCH (Table 5).
At CHRACERH, all the cesarean sections of group 5 were indicated for scarred uterus (100%). At YCH, scarred uterus was the principal indication of cesarean sections within group 5 (65%). Many more cesarean sections were indicated for scarred uterus in CHRACERH than in YCH, with a statistically significant difference (p < 0.05) (Table 6).
At CHRACERH, groups 1, 2 and 5 had the highest rates of complications. Hemorrhagic and infectious complications were the most common in group5. In groups 1 and 2, the complications were exclusively hemorrhagic (Table 7).
At YCH, groups 1, 3 and 2 had the highest rates of maternal complications. The complications were mainly infectious in groups 1 and 3. In group 2, the complications were exclusively hemorrhagic. Other complications like thromboembolic complications, digestive and urinary tract injuries were neglectable (Table 8).
Groups 1, 2 and 3 had the highest fetal complications at CHRACERH. In group1, we had; neonatal infection in 66.7% of neonates delivered by cesarean sections (Table 9).
At YCH, groups 1, 3 and 10 had the highest rates of global fetal complications.
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Table 2. Age distribution of the study population.
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Table 3. Contribution of different Robson’s groups to cesarean section rates at CHRACERH and at YCH.
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Table 4. Indications of Cesarean Section within Robson’s group1 at CHRACERH and YCH.
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Table 5. Indications of cesarean section in Robson’s group 3 at CHRACERH and at YCH.
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Table 6. Indications of Cesarean Section within Robson’s group 5 at CHRACERH and YCH.
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Table 7. Early maternal outcome after cesarean section according to Robson’s groups at CHRACERH.
At CHRACERH, groups 5, 2 and 3 were the highest contributors to poor maternal outcome. The most frequent complications were due to postpartum hemorrhage.
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Table 8. Early maternal outcome after cesarean section according to Robson’s groups at YCH.
At YCH, groups 1, 3 and 2 were the highest contributors to poor maternal outcome. The most frequent complications were due to infections in group 1 and 3 and postpartum hemorrhage in group 2.
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Table 9. Early fetal outcome after cesarean section according to Robson’s groups at CHRACERH.
At CHRACERH the highest contribution to fetal complications came from cesarean deliveries in groups 1, 2 and 3 respectively. The most frequent complication was neonatal infection
In group 2, we had neonatal asphyxia and neonatal infection, each in 33.3% (Table 10).
4. Limitations of the Study
We encountered some difficulties and limitations, namely:
· The retrospective nature of data collection following which patient files were excluded for missing key data.
· Restricted access to the HCY archives room which opened at 8:00 a.m. and closed at 3:30 p.m. making our data collecting difficult.
5. Discussion
The mean age of the parturients at CHRACERH was 31.2 ± 5.07 years. This is similar to that of Mbungu et al. in 2017 in RDC in which the mean age was 30.07 ± 6.25 years [14] . The mean age of patients at YCH was 27 ± 6.01 years. Other authors reported a mean age similar to ours; Kemfang et al. in 2015 in Cameroun with a mean age of 28.1 ± 0.93 years [8] , Xavier Kinenkinda et al. in 2017 in RDC, who reported a mean age of 28.8 ± 6.8 years [15] . There was a statistically significant difference between the age of patients at CHRACERH and those of YCH. This could be due to the fact that CHRACERH is a reference center receiving an important pool of patients consulting for infertility problems, mostly at an advanced age.
The socio-professional class which was the most represented at CHRACERH
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Table 10. Early fetal outcome after cesarean section according to Robson’s groups at YCH.
At YCH the highest contribution to fetal complications came from cesarean deliveries in groups 1, 3 and 10 respectively. The most common complication was neonatal asphyxia.
was that of public servants; 34.0%. The socio-professional class which was the most represented at of YCH was that of unemployed women making up 37.7% of patients, similar to that reported by Mbungu et al. in 2017 in RDC who reported that majority i.e., 74.2% of parturients in their study were unemployed [14] . There was a statistically significant difference (P < 0.05) between the unemployed women at CHRACERH and those of YCH. This could be due to the fact that the cost of health care is more affordable at YCH than at CHRACERH, hence parturients who are more financially stable sought the services of CHRACERH.
In our study, the rate of cesarean section was at 27.2% at CHRACERH and 24.8 % at YCH. These findings were in accordance with those of literature which report a global increase in the rate of cesarean sections [2] , way above the limit of 15% recommended by WHO [1] . Certain authors found results similar to ours; Mbungu et al. in 2017 in RDC reported 31.2% [14] . Hehir et al. in 2018 in the United States of America reported a global cesarean section rate of 31.6% [16] .
This rise of cesarean section in our context could be explained by; advanced maternal age, an increase in the frequency of scarred uterus, the fear of complication of vaginal delivery, vulgarization of medically assisted procreation associated with a high frequency of associated multiple gestation.
At CHRACERH and YCH, groups 1, 3 and 5 were the groups with the highest rates of cesarean sections. This result is similar to that of Tura et al. in 2018 who reported groups 3, 5 and 1 with global cesarean rates of 21.4%, 21.1% and 19.3% respectively [17] . The high rates in groups 1 and 3 could be due to the relatively large sizes of these groups in the parturients’ population. Concerning the great contribution of group 5 in the rate of cesarean section, this could be explained by the increase in the frequency of scarred uterus in the population.
At CHRACERH, most of the cesarean sections of group 1 were indicated for acute fetal distress at 28.6%. This result was similar to that of Tahira et al. in 2012 at Muscat who reported that acute fetal distress was the principal indication of cesarean sections in group1 [18] . At YCH, most cesarean sections of group 1 were indicated for cephalopelvic disproportion i.e., 36.7%. This difference was probably due to differences in technical support, monitoring of parturients was easier at CHRACERH compared to HCY due to the availability of cardiotocographs at CHRACERH. Moreover, contrary to CHRACERH, YCH receives more parturients referred from surrounding health centers usually with poor pregnancy follow up, in stationnarylabour for continuation of care.
Cephalopelvic disproportion was the predominant indication of cesarean section in groups 3 of both CHRACERH and YCH at 44.4% and 39.2% respectively. These results were similar to those of Tura et al. in 2018 in Ethiopia who reported that cephalopelvic disproportion was the predominant indication of cesarean section in groups 3 with 35.2% [17] .
In group 5, we had more cesarean sections indicated for scarred uterus at CHRACERH than at YCH, the difference was statistically significant (p < 0.05). At CHRACERH, we noticed that all the women (82.4%) who underwent a cesarean section, all had as indication a scarred uterus (100%). At YCH 78.4% of women in group 5 had delivered cesarean section. This could be explained by the small sample size at CHRACERH. Tura et al. in 2018 in Ethiopia had equally obtained uterine scar like the main indication for cesarean section in group 5 with 65% [17] .
At CHRACERH, the groups which had the highest rates of maternal complications were groups 5, 1 and 2 with 50%, 25% et 25% respectively. The complications were hemorrhagic (50%) and infectious (50%) in group 5. In groups 1 and 2, the complications were only hemorrhagic (100%). At the YCH, the groups with the highest maternal complications were groups 1, 3 and 2 respectively with 43.3%, 24.3% and 13.5%. The complications were principally infectious at 68.8% and 66.7% in groups 1 et 3. In group 2, the complications were solely hemorrhagic at 100%. These results were due to the fact that hemorrhage is a very common happening during deliveries. Infections remain frequent in our setting.
At CHRACERH, groups 1, 2 and 3 had the highest fetal complications at 25% each. In group 1, we had: neonatal infections and transfer to the neonatal unit in 66.7% of children delivered by cesarean section. In group 2, we had neonatal asphyxia and neonatal infections in 33.3% each. At YCH, groups 1, 3 and 10 had the highest rates of fetal complications notably 27.1%, 21.5% and 13.8% respectively. In groups 1, 2 and 10 of YCH, neonatal infection was the main neonatal complication at 44.4%, 50% and 33.3% respectively. This could be explained by the high frequency of fetal morbidity in relation with surgery.
6. Conclusion
The Robson’s classification is an important tool in the evaluation of cesarean section rates in health facilities. In our context, the rates of cesarean section are high. Groups 1, 3 and 5 were the groups with the highest rates of cesarean sections at CHRACERH and YCH. The principal indications of cesarean sections in groups 1, 3 and 5 were respectively acute fetal distress, cephalopelvic disproportion and scarred uterus at CHRACERH. At YCH, they were cephalopelvic disproportion in groups 1 and 3 and scarred uterus in group 5.
Appendix: Questionnaire