Use of the Robson classification has improved understanding of caesarean section rates in France

The rise of caesarean section (CS) rates worldwide has implications for the health of women and their newborns. Ecological analyses suggest that for many lower-income countries, even small increases in CS rates (if performed in women with a medical indication for CS) could dramatically reduce maternal and newborn mortality (Althabe et al., Birth, 2006;4:270–7) and are long overdue. With higher CS rates, such as those seen in many higher-income countries, the effects on health are much less clear; increasing use of CS without medical indications may well be causing more harm than good (Souza et al., BMC Med 2010;8:71). There is considerable debate as to why this unprecedented increase in the use of CS is occurring, and when and how CS usage can be safely reduced. A standardised, universally accepted CS classification system applied to facility- or national-level data sets to monitor CS rates would go a long way towards answering these questions, as well as permitting reliable international comparisons. On the basis of systematic reviews, the Robson 10-group classification system has emerged as the most appropriate tool to fulfil this need and can be implemented and interpreted at facility, national and international levels with relative ease (Torloni et al., PLoS ONE 2011;6:e14566; Betran et al., PLoS ONE 2013;9:e97769). In this new study, Le Ray and colleagues have applied the Robson classification to three French population-representative, cross-sectional perinatal surveys in 1995, 2003 and 2010 to analyse the obstetric population and changes in CS rates over time. Stabilisation of the overall CS rate in France from 2003 to 2010 at around 20% (following a roughly 5% increase from 1995 to 2003) seems promising at first glance, given that risk factors for CS appeared to be increasing over time. However, the overall CS rate belies underlying trends in French obstetric practices that are worthy of closer attention. Particularly, from 2003 to 2010, CS use amongst nulliparous women in spontaneous and induced labour increased, even while the use of CS before labour in nulliparous women decreased. Although the CS rate in women with a previous CS was 61.2% at both time points, the growing number of women in the community with a CS scar means the contribution of this group to the overall CS rate grew over time. Le Ray and colleagues have demonstrated how the Robson classification can be applied effectively at national level and over multiple time points, despite changes in practices and population characteristics. The Robson classification can be useful at facility and population levels to identify which specific groups to target and to help develop policy options to reduce unnecessary CS. The authors report no conflicts of interest.