# Ensuring Quality by a Clinical Audit of the Mode of Birth: The Use of the Robson Classification System

## TL;DR

This study uses the Robson classification to identify factors linked to high cesarean section rates in Greece, aiming to improve obstetric care quality.

## Contribution

The study applies the Robson classification system in a Greek hospital to identify predictors of cesarean sections in low-risk groups.

## Key findings

- Smoking, IVF, and maternal conditions were significant predictors of cesarean sections in Robson 1.
- Greek nationality and high birth weight were significant predictors in Robson 2a.
- Younger maternal age and full-term gestation were associated with lower cesarean risk.

## Abstract

Background

The overuse of cesarean section (CS) leads to risks in maternal and neonatal health. One of the highest rates of CS in Europe is observed in Greece, making it essential to understand the factors contributing to this elevated rate, especially among low-risk groups. The implementation of the Robson classification as a clinical audit tool is a key step in enhancing the quality of obstetric and midwifery care, allowing for the systematic monitoring and evaluation of the mode of delivery. The present study aimed to identify the clinical and demographic predictors of CS in women classified in Robson 1 and 2a categories, based on deliveries conducted in 2019 at a private hospital in Athens, Greece.

Methodology

A retrospective analysis was conducted employing data from 8,572 deliveries in 2019 at a private hospital in Athens by classifying women based on the Robson classification. Multiple logistic regression analysis was performed to identify significant predictors in the two groups.

Results

For the Robson 1 category, the significant predictors were smoking during pregnancy (odds ratio (OR) = 1.75, p = 0.001), use of in vitro fertilization (IVF) (OR = 2.22, p = 0.002), presence of pre-existing maternal conditions (OR = 1.50, p = 0.014), and fetal-related pregnancy pathology (OR = 3.90, p = 0.013). In addition, maternal age between 20 and 29 years was associated with significantly lower odds of CS compared to those aged 30-39 years (OR = 0.65, p=0.022), while gestational age of 39+0 to 41+6 weeks compared to 37+0 to 38+6 weeks (OR = 0.60, p<0.0001) was also linked to lower risk. For the Robson 2a category, the significant predictors were Greek nationality (OR = 1.91, p < 0.0005), smoking during pregnancy (OR = 1.91, p < 0.0005), IVF conception (OR = 1.51, p = 0.044), and neonatal birth weight ≥4,000 g (OR = 2.95, p < 0.0005). On the contrary, reduced odds were noted for maternal age between 20 and 29 years in comparison to the 30-39-year group (OR = 0.70, p = 0.005). The presence of gestational diabetes (OR = 0.66, p = 0.019) and neonatal birth weight below 3,000 g (OR = 0.73, p = 0.027) were also protective factors.

Conclusions

The use of the Robson classification as a clinical audit tool facilitates the identification of clinical practice patterns associated with the increased CS rates, contributing to the targeted improvement of perinatal quality of care.