The current study analyzed 2322500 in-hospital deliveries in Iran and categorized them using the Robson classification system to describe and compare cesarean section rates.
Between 21 March 2019 and 21 March 2021, the CS rate was 51.63% in Iran, which is considerably higher than many countries as well as the WHO recommended rates. The rate of cesarean sections in nulliparous women in Iran in two consecutive years was 52.4%. Although Robson group 5 was the largest contributing group to the total CSs (47.1%), the government's approach is to reduce the CS rate in nulliparous women based on Natural Birth Promotion program(14, 15). Given that 31.3% of all cesarean deliveries were belonged to groups 1 and 2, the application of the Robson classification system provides a better understanding of the CS rates and population variations among maternity units across provincial and national levels. Our study showed that Robson groups 1 to 4 accounted for about 63.9% of the obstetric population in Iran. Such that 37.6 % of the population was attributed to nulliparous women with a singleton, term, cephalic pregnancy, and no previous cesarean delivery (Robson Groups 1 and 2).
The Nordic countries such as Netherlands, Iceland, and Norway are reported to have low CS rates across all groups of Robson with high quality of obstetric care resulting in good perinatal outcomes (16). In the Netherlands, for instance, 39.9% of the total deliveries contribute to Robson group 1 and 2, which is similar to the population of the same groups in Iran. However, the CS rates in these groups vary significantly between the two countries. That is to say, CS rates in groups 1 and 2 in the Netherlands are 9.6%, and 28.9% (within the WHO recommended ranges), while the corresponding proportions are 33.07% and 63.23%, respectively, in Iran (17). Iceland implemented a CS auditing program using the Robson classification in 2000 which had led to a significant decrease in CS rate by the end of 2011 (16). This is an evidence-based example of achieving positive results by benchmarking and implementing a monitoring program to reduce cesarean deliveries.
In a Canadian study using the Robson classification, group 5 was the largest contributing group to the overall cesarean deliveries (36.6%), and groups 2 and 1 ranked as the second-and third-largest contribution (15.7% and 14.1%, respectively) (18), the same pattern was identified in our study. Given that in Iran, the majority of the obstetric population attributes to Robson groups 1 and 2, reducing CSs among nulliparous women would be highly effective in reducing the total national CS rate, as these women will contribute to group 5 population in the future. This could be achieved through quality improvement strategies focused on interventions such as auditing the hospitals by the use of the Robson classification system, review of patient records for CS indications, feedback for the health providers, revision and monitoring of labour and delivery management guidelines, and application of benchmarking and best practices.
The results of the present study show that the private sector plays an important role in the rise of CS rates in Robson groups 1, 2, 3, 4, and 10. A similar situation has been observed in Brazil’s private sector (19). Precursors of the high CS rate in the private sector to increase hospital income are the lack of adherence to the national guideline for elective CS, the low use of induction, and abuse of the unconscious interest in CS among new mothers. Eyi et al. reported the same pattern in Turkey (20). Robson groups 5, 3, 2, 1, 4, and 10, identified as the main contributors to the CS rate, were targeted for interventions. Authors suggested commercialization of the health care system as a public policy directed at the private sector, where CS indication seems not to be driven by medical reasons.
Iran’s national health policy for Natural Birth Promotion program (3, 14, 15) is to reduce the CS rate through reducing nulliparous cesareans. To achieve this goal, the Iranian Ministry of Health should set its goals on the Robson classification system in auditing the CS rates at the hospital level for Robson groups 1 and 2. This would make an appropriate benchmarking process to compare the obstetrics and perinatal quality of care among maternity units and improve management of normal labour and birth.
To our knowledge, this is the first Iranian study to assess CS rates using the Robson classification system based on the national birth registry database. We used a registry database at the national level, as well as a standard classification system, providing a logical comparison with other nations. Another strength of the present study is the comprehensive database of the IMaN that provides information at the hospital, medical university, and national level. This information are vital in implementing strategies and auditing the outcomes at local and national’s levels. This study had several limitations. One limitation of the study is that we did not analyze the maternal and neonatal outcomes in each Robson group. Therefore, the associations between higher CS rates and obstetric outcomes were lacking. Moreover, the Robson criteria on the IMaN registry database were not available before 21 March 2019. It is recommended that future studies focus on maternal and perinatal outcomes and CS rate trends of consecutive years using Robson classification.