Table 1
The Robson’s Grouping system for caesarean deliveries.
| Robson 1 (R1) | Nullipar, single cephalic, ≥37 weeks, spontaneous labour |
| Robson 2 (R2) | Nullipar, single cephalic, ≥37 weeks, induced |
| Robson 3 (R3) | Multipar (excluding previous caesareans), single cephalic, ≥37 weeks, spontaneous labour |
| Robson 4 (R4) | Multipar (excluding previous caesareans), single cephalic, ≥37 weeks, induced |
| Robson 5 (R5) | Previous caesarean, single cephalic ≥37 weeks |
| Robson 6 (R6) | All nullipar breeches |
| Robson 7 (R7) | All multipar breeches (including previous caesareans) |
| Robson 8 (R8) | All multiple pregnancies (including previous caesareans) |
| Robson 9 (R9) | All abnormal lies (including previous caesareans) |
| Robson 10 (R10) | All single cephalic, ≤36 weeks (including previous caesareans) |
Table 2
Number of livebirth and rates to Robson’s groups (n = 5,323,500).
| 2013 | 2014 | 2015 | 2016 | 4 Years Total | ||||||
|---|---|---|---|---|---|---|---|---|---|---|
| (%) | Number | (%) | Number | (%) | Number | (%) | Number | % | Number | |
| Robson 1 | 22.7 | 294,189 | 23 | 318,415 | 23.1 | 307,999 | 23.1 | 302,557 | 22.98% | 1,223,160 |
| Robson 2 | 10.8 | 139,967 | 10.6 | 146,748 | 10.3 | 137,333 | 9.7 | 127,048 | 10.35% | 551,095 |
| Robson 3 | 25.9 | 335,661 | 24.7 | 341,950 | 24.4 | 325,332 | 26.1 | 341,850 | 25.26% | 1,344,793 |
| Robson 4 | 7.6 | 98,495 | 7.8 | 107,984 | 7.2 | 96,000 | 7.1 | 92,994 | 7.43% | 395,473 |
| Robson 5 | 22.2 | 287,709 | 23.2 | 321,184 | 24.1 | 321,332 | 24.3 | 318,274 | 23.45% | 1,248,500 |
| Robson 6 | 2.6 | 3,696 | 2.6 | 35,995 | 2.6 | 34,667 | 2.3 | 30,125 | 2.53% | 134,482 |
| Robson 7 | 1.8 | 23,328 | 1.9 | 26,304 | 1.9 | 25,333 | 1.7 | 22,266 | 1.83% | 97,231 |
| Robson 8 | 1.4 | 18,144 | 1.4 | 19,382 | 1.3 | 17,333 | 1.3 | 17,027 | 1.35% | 71,886 |
| Robson 9 | 1.7 | 22,032 | 1.7 | 23,535 | 1.6 | 21,333 | 1.3 | 17,027 | 1.58% | 83,927 |
| Robson 10 | 3.3 | 42,768 | 3.1 | 42,917 | 3.5 | 46,667 | 3.1 | 40,603 | 3.25% | 172,954 |
| Total | 100 | 100 | 100 | 100 | 100 | |||||
| Total R1-R4 groups | 67.0 | 868,311 | 66.1 | 915,097 | 65.0 | 866,664 | 66.0 | 864,449 | 66.02% | 3,514,521 |
| Total C-section | 51.4% | 665,547 | 52.6% | 727,609 | 53.6% | 714,636 | 50.1% | 656,582 | 48.1% | 2,764,373 |
| Total Vaginal Deliveries | 48.6% | 630,441 | 47.4% | 656,804 | 46.4% | 618,693 | 49.9% | 653,189 | 48.1% | 2,559,127 |
| Total Live-Birth number | 1,295,987 | 1,384,413 | 1,333,329 | 1,309,771 | 5,323,500 | |||||
Table 3
C-Section rate in each group (number of C-Section/Number of Livebirth %) (livebirth n = 5,323,500).
| 2013 | 2014 | 2015 | 2016 | 4 Years Total | ||||||
|---|---|---|---|---|---|---|---|---|---|---|
| Number of Caesarean | Caesarean rate % | Number of Caesarean | Caesarean rate % | Number of Caesarean | Caesarean rate % | Number of Caesarean | Caesarean rate % | Number of Caesarean | Caesarean rate % | |
| Robson 1 | 100,024 | 34 | 108,261 | 34 | 106,568 | 34.6 | 91,372 | 30.2 | 406,225 | 33.2% |
| Robson 2 | 88,739 | 63.4 | 93,625 | 63.8 | 91,189 | 66.4 | 78,643 | 61.9 | 352,196 | 63.9% |
| Robson 3 | 43,972 | 13.1 | 46,505 | 13.6 | 41,317 | 12.7 | 36,920 | 10.8 | 168,714 | 12.5% |
| Robson 4 | 40,580 | 41.2 | 44,489 | 41.2 | 41,856 | 43.6 | 36,175 | 38.9 | 163,100 | 41.2% |
| Robson 5 | 277,352 | 96.4 | 311,869 | 97.1 | 311,692 | 97 | 309,044 | 97.1 | 1,209,958 | 96.9% |
| Robson 6 | 30,730 | 91.2 | 32,323 | 89.8 | 31,269 | 90.2 | 25,998 | 86.3 | 120,321 | 89.5% |
| Robson 7 | 20,342 | 87.2 | 22,069 | 83.9 | 22,116 | 87.3 | 19,683 | 88.4 | 84,210 | 86.6% |
| Robson 8 | 15,567 | 85.8 | 17,715 | 91.4 | 16,311 | 94.1 | 15,767 | 92.6 | 65,360 | 90.9% |
| Robson 9 | 19,586 | 88.9 | 20,452 | 86.9 | 18,859 | 88.4 | 15,086 | 88.6 | 73,983 | 88.2% |
| Robson 10 | 28,654 | 67 | 30,299 | 70.6 | 33,460 | 71.7 | 27,894 | 68.7 | 120,308 | 69.6% |
| TOTAL Caesarean | 665,546 | 51.4% | 727,609 | 52.6% | 714,636 | 53.6% | 656,582 | 50.1% | 2,764,373 | 51.9% |
| Vaginal Deliveries | 630,441 | 48.6% | 656,804 | 47.4% | 618,693 | 46.4% | 653,189 | 49.1% | 2,559,127 | 48.1% |
| TOTAL Livebirth | 1,295,997 | 100% | 1,384,413 | 100% | 1,333,329 | 100% | 1,309,771 | 100% | 5,323,500 | 100% |
Table 4
Relative contribution made by each Robson group to overall C-Section rate (number of C-Section in each group/number of total yearly C-Section %) (4 years total livebirth n = 2,764,373).
| 2013 | 2014 | 2015 | 2016 | 4 Years Total | |
|---|---|---|---|---|---|
| Robson 1 | 15.0% | 14.9% | 14.9% | 13.9% | 14.7% |
| Robson 2 | 13.3% | 12.9% | 12.8% | 1.,0% | 12.7% |
| Robson 3 | 6.6% | 6.4% | 5.8% | 5.6% | 6.1% |
| Robson 4 | 6.1% | 6.1% | 5.9% | 5.5% | 5.9% |
| Robson 5 | 41.7% | 42.9% | 43.6% | 47.1% | 43.8% |
| Robson 6 | 4.6% | 4.4% | 4.4% | 4.0% | 4.4% |
| Robson 7 | 3.1% | 3.0% | 3.1% | 3.0% | 3.0% |
| Robson 8 | 2.3% | 2.4% | 2.3% | 2.4% | 2.4% |
| Robson 9 | 2.9% | 2.8% | 2.6% | 2.3% | 2.7% |
| Robson 10 | 4.3% | 4.2% | 4.7% | 4.2% | 4.4% |
| TOTAL | 100% | 100% | 100% | 100% | 100% |
Table 5
Caesarean rates of Robson’s groups by hospital types (%).
| Hospital Groups | Robson 1 | Robson 2 | Robson 3 | Robson 4 | Robson 5 | Robson 6 | Robson 7 | Robson 8 | Robson 9 | Robson 10 | |
|---|---|---|---|---|---|---|---|---|---|---|---|
| 2013 | Public State | 21.2 | 44.1 | 7.4 | 26.6 | 95.9 | 93.1 | 83.6 | 80.0 | 91.5 | 50.4 |
| Private | 48.1 | 76.5 | 27.2 | 59.1 | 96.7 | 90.5 | 88.6 | 89.7 | 88.3 | 80.3 | |
| University | 40.5 | 68.1 | 20.9 | 52.3 | 97 | 90.3 | 89.1 | 84.0 | 88.5 | 64.1 | |
| Caesarean rate | 34.0 | 63.4 | 13.1 | 41.2 | 96.4 | 91.2 | 87.2 | 85.8 | 88.9 | 67.0 | |
| 2014 | Public State | 19.8 | 46.4 | 7.6 | 26.5 | 97.3 | 87.1 | 74.3 | 86.3 | 80.9 | 56.3 |
| Private | 51.9 | 75.8 | 29.3 | 58.4 | 96.9 | 90.8 | 88.5 | 94.4 | 88.7 | 80.4 | |
| University | 39.4 | 64.6 | 22.2 | 60.5 | 97.8 | 90.2 | 88.1 | 91.6 | 90.2 | 69.1 | |
| Caesarean rate | 34.0 | 63.8 | 13.6 | 41.2 | 97.1 | 89.8 | 83.9 | 91.4 | 86.9 | 70.6 | |
| 2015 | Public State | 19.0 | 51.6 | 6.5 | 30.6 | 97.5 | 86.3 | 83.5 | 87.6 | 80.3 | 59.3 |
| Private | 53.6 | 75.7 | 29.9 | 56.9 | 96.8 | 92.3 | 89.0 | 98.5 | 90.1 | 80.8 | |
| University | 47.1 | 70.3 | 37.4 | 58.3 | 95.3 | 83.2 | 87.4 | 95.0 | 88.2 | 72.7 | |
| Caesarean rate | 34.6 | 66.4 | 12.7 | 43.6 | 97.0 | 90.2 | 87.3 | 94.1 | 88.4 | 71.7 | |
| 2016 | Public State | 18.3 | 50.4 | 6.9 | 29 | 97.5 | 79.9 | 87.2 | 87.6 | 81 | 57.5 |
| Private | 52.6 | 74.4 | 27.9 | 56.6 | 96.6 | 91.2 | 89.5 | 97.6 | 91.1 | 82 | |
| University | 47 | 71.6 | 32.3 | 60 | 95.38 | 83.6 | 87.4 | 95.3 | 86.4 | 71.2 | |
| Caesarean rate | 30.2 | 61.9 | 10.8 | 38.9 | 97.1 | 86.3 | 88.4 | 92.6 | 88.6 | 68.7 |
Table 6
Top 10 recommended interventions for reducing the caesarean rate in Turkey.
| What to do | Why to do | Who to do | |
|---|---|---|---|
| 1 | Measures and incentives should be developed for the private sector. | To reduce private sector caesarean rate to the public hospital level. | MoH Ministry of Finance Reimbursement Agencies |
| 2 | “The Vaginal Delivery Right” should be discussed and an agenda should be created. | To raise awareness for all parties (healthworker-pregnants-families). | MoH Universities NGOs |
| 3 | Healthcare providers (hospitals/obstetricians) should be motivated to create and lead corrective actions. Feedback to both the physician and the institution should be made about their caesarean rate by MoH. | To support and divert healthcare professionals’ and institutions’ motivation towards vaginal delivery with feedback | MoH Specialty Boards Specialty associations |
| 4 | It should be ensured that the residents who are on obstetrics training in a hospital with less than 500 vaginal deliveries per year spend one year of their education in hospitals with more vaginal deliveries. | To train future obstetricians with more experience in vaginal delivery. | MoH Universities Specialty Boards Specialty Associations |
| 5 | Regional obstetrical reference centers should be determined for vaginal birth after caesarean (VBAC). | To reduce the secondary caesarean rate due to previous caesarean indication | MoH |
| 6 | Midwifery should be encouraged and pregnancy coach (doula) should be included in the system. | To increase the number of healthcare professionals in favour of vaginal birth | MoH Universities Policy makers |
| 7 | Antenatal educational activities for expectant about pregnancy, birth, and postpartum periods should be strengthened. | Guidance of expectant to vaginal delivery by educating that pregnancy process is a natural cycle, vaginal birth is more natural, and it is possible to switch to natural life cycle easily afterwards. | Public Hospital Private Hospital Practitioners MoH NGOs |
| 8 | The use of “Mother and Baby web-TV (www.annevebebek.gov.tr)” which is still live should be supported and its content should be enriched. | To provide access to reliable information to expectant mothers regardless of time and location | MoH Universities NGOs Private Hospital |
| 9 | Guidelines for the birth process should be updated and compliance should be followed on the basis of institution or department. | To evaluate the reason for the caesarean decision and also to obtain statistical data for follow-up | Universities MoH |
| 10 | Supporting and providing legal counselling to healthcare professionals in malpractice cases encountered during and after birth | Since the birth process is considered risky by healthcare workers and they are afraid of malpractice cases that may arise due to problems that may arise due to this, institutions take a stance in favour of caesarean. | Policy Makers MoH Private Sector Specialty Associations |