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Background: In most regions worldwide, caesarean section (CS) rates are increasing. In these settings, new strategies are needed to reduce CS rates., Objectives: To identify, critically appraise and synthesise studies using the Robson classification as a system to categorise and analyse data in clinical audit cycles to reduce CS rates., Search Strategy: Medline, Embase, CINAHL and LILACS were searched from 2001 to 2016., Selection Criteria: Studies reporting use of the Robson classification to categorise and analyse data in clinical audit cycles to reduce CS rates., Data Collection: Data on study design, interventions used, CS rates, and perinatal outcomes were extracted., Results: Of 385 citations, 30 were assessed for full text review and six studies, conducted in Brazil, Chile, Italy and Sweden, were included. All studies measured initial CS rates, provided feedback and monitored performance using the Robson classification. In two studies, the audit cycle consisted exclusively of feedback using the Robson classification; the other four used audit and feedback as part of a multifaceted intervention. Baseline CS rates ranged from 20 to 36.8%; after the intervention, CS rates ranged from 3.1 to 21.2%. No studies were randomised or controlled and all had a high risk of bias., Conclusion: We identified six studies using the Robson classification within clinical audit cycles to reduce CS rates. All six report reductions in CS rates; however, results should be interpreted with caution because of limited methodological quality. Future trials are needed to evaluate the role of the Robson classification within audit cycles aimed at reducing CS rates., Tweetable Abstract: Use of the Robson classification in clinical audit cycles to reduce caesarean rates., (© 2017 The Authors. BJOG An International Journal of Obstetrics and Gynaecology published by John Wiley & Sons Ltd on behalf of Royal College of Obstetricians and Gynaecologists.)

Objective: Caesarean section was initially performed to save the lives of the mother and/or her baby. Caesarean section rates have risen substantially worldwide over the past decades. In this study, we set out to compile all available caesarean section rates worldwide at the country level, and to identify the appropriate caesarean section rate at the population level associated with the minimal maternal and neonatal mortality., Design: Ecological study using longitudinal data., Setting: Worldwide country-level data., Population: A total of 159 countries were included in the analyses, representing 98.0% of global live births (2005)., Methods: Nationally representative caesarean section rates from 2000 to 2012 were compiled. We assessed the relationship between caesarean section rates and mortality outcomes, adjusting for socio-economic development by means of human development index (HDI) using fractional polynomial regression models., Main Outcome Measures: Maternal mortality ratio and neonatal mortality rate., Results: Most countries have experienced increases in caesarean section rate during the study period. In the unadjusted analysis, there was a negative association between caesarean section rates and mortality outcomes for low caesarean section rates, especially among the least developed countries. After adjusting for HDI, this effect was much smaller and was only observed below a caesarean section rate of 5-10%. No important association between the caesarean section rate and maternal and neonatal mortality was observed when the caesarean section rate exceeded 10%., Conclusions: Although caesarean section is an effective intervention to save maternal and infant lives, based on the available ecological evidence, caesarean section rates higher than around 10% at the population level are not associated with decreases in maternal and neonatal mortality rates, and thus may not be necessary to achieve the lowest maternal and neonatal mortality., Tweetable Abstract: The caesarean section rate of around 10% may be the optimal rate to achieve the lowest mortality., (© 2015 The Authors BJOG An International Journal of Obstetrics and Gynaecology published by John Wiley & Sons Ltd on behalf of Royal College of Obstetricians and Gynaecologists.)

Objective: To generate a global reference for caesarean section (CS) rates at health facilities., Design: Cross-sectional study., Setting: Health facilities from 43 countries., Population/sample: Thirty eight thousand three hundred and twenty-four women giving birth from 22 countries for model building and 10,045,875 women giving birth from 43 countries for model testing., Methods: We hypothesised that mathematical models could determine the relationship between clinical-obstetric characteristics and CS. These models generated probabilities of CS that could be compared with the observed CS rates. We devised a three-step approach to generate the global benchmark of CS rates at health facilities: creation of a multi-country reference population, building mathematical models, and testing these models., Main Outcome Measures: Area under the ROC curves, diagnostic odds ratio, expected CS rate, observed CS rate., Results: According to the different versions of the model, areas under the ROC curves suggested a good discriminatory capacity of C-Model, with summary estimates ranging from 0.832 to 0.844. The C-Model was able to generate expected CS rates adjusted for the case-mix of the obstetric population. We have also prepared an e-calculator to facilitate use of C-Model (www.who.int/reproductivehealth/publications/maternal_perinatal_health/c-model/en/)., Conclusions: This article describes the development of a global reference for CS rates. Based on maternal characteristics, this tool was able to generate an individualised expected CS rate for health facilities or groups of health facilities. With C-Model, obstetric teams, health system managers, health facilities, health insurance companies, and governments can produce a customised reference CS rate for assessing use (and overuse) of CS., Tweetable Abstract: The C-Model provides a customized benchmark for caesarean section rates in health facilities and systems., (© 2015 World Health Organization; licensed by John Wiley & Sons Ltd on behalf of Royal College of Obstetricians and Gynaecologists.)

Objective: To examine the quality and completeness of information on caesarean section in web pages used by laypersons in Brazil, a country with very high rates of caesarean delivery., Design: Cross-sectional study., Setting: Brazil., Sample: A total of 176 Internet websites., Methods: The term 'caesarean delivery' and 25 synonyms were entered into the most popular search engines in Brazil. The first three pages of hits were downloaded and assessed by two independent investigators using the DISCERN instrument and a content checklist., Main Outcome Measures: Quality and completeness of information on caesarean section., Results: A total of 3900 web pages were retrieved and 176 fulfilled the selection criteria. The overall average DISCERN score was 43.6 (±8.9 SD), of a maximum score of 75; 30% of the pages were of poor or very poor quality and 47% were of moderate quality. Most pages scored low, especially in questions related to reliability of the information. The most frequently covered topics were: indications for caesarean section (80% of websites), which did not reflect clinical practice; short-term maternal risks (80%); and potential benefits of caesarean section (56%), including maternal and doctor convenience. Less than half of the websites mentioned perinatal risks and less than one-third mentioned long-term maternal risks associated with caesarean section, such as uterine rupture (17%) or placenta praevia/accreta (12%) in future pregnancies., Conclusions: The quality and completeness of web-based resources in Portuguese about caesarean section were poor to moderate. Pending improvement of these resources, obstetricians should warn pregnant women about these facts and encourage them to discuss what they have read on the Internet about caesarean section., Tweetable Abstract: The quality and completeness of information about caesareans is poor in 176 websites used by Brazilians., (© 2014 Royal College of Obstetricians and Gynaecologists.)

Objectives: Caesarean section (CS) rates are increasing worldwide and maternal request is cited as one of the main reasons for this trend. Women's preferences for route of delivery are influenced by popular media, including magazines. We assessed the information on CS presented in Spanish women's magazines., Design: Systematic review., Setting: Women's magazines printed from 1989 to 2009 with the largest national distribution., Sample: Articles with any information on CS., Methods: Articles were selected, read and abstracted in duplicate. Sources of information, scientific accuracy, comprehensiveness and women's testimonials were objectively extracted using a content analysis form designed for this study., Main Outcome Measures: Accuracy, comprehensiveness and sources of information., Results: Most (67%) of the 1223 selected articles presented exclusively personal opinion/birth stories, 12% reported the potential benefits of CS, 26% mentioned the short-term and 10% mentioned the long-term maternal risks, and 6% highlighted the perinatal risks of CS. The most frequent short-term risks were the increased time for maternal recovery (n = 86), frustration/feelings of failure (n = 83) and increased post-surgical pain (n = 71). The most frequently cited long-term risks were uterine rupture (n = 57) and the need for another CS in any subsequent pregnancy (n = 42). Less than 5% of the selected articles reported that CS could increase the risks of infection (n = 53), haemorrhage (n = 31) or placenta praevia/accreta in future pregnancies (n = 6). The sources of information were not reported by 68% of the articles., Conclusions: The portrayal of CS in Spanish women's magazines is not sufficiently comprehensive and does not provide adequate important information to help the readership to understand the real benefits and risks of this route of delivery., (© 2014 The Authors. BJOG An International Journal of Obstetrics and Gynaecology published by John Wiley & Sons Ltd on behalf of Royal College of Obstetricians and Gynaecologists.)

Background: In most regions worldwide, caesarean section (CS) rates are increasing. In these settings, new strategies are needed to reduce CS rates.Objectives: To identify, critically appraise and synthesise studies using the Robson classification as a system to categorise and analyse data in clinical audit cycles to reduce CS rates.Search Strategy: Medline, Embase, CINAHL and LILACS were searched from 2001 to 2016.Selection Criteria: Studies reporting use of the Robson classification to categorise and analyse data in clinical audit cycles to reduce CS rates.Data Collection: Data on study design, interventions used, CS rates, and perinatal outcomes were extracted.Results: Of 385 citations, 30 were assessed for full text review and six studies, conducted in Brazil, Chile, Italy and Sweden, were included. All studies measured initial CS rates, provided feedback and monitored performance using the Robson classification. In two studies, the audit cycle consisted exclusively of feedback using the Robson classification; the other four used audit and feedback as part of a multifaceted intervention. Baseline CS rates ranged from 20 to 36.8%; after the intervention, CS rates ranged from 3.1 to 21.2%. No studies were randomised or controlled and all had a high risk of bias.Conclusion: We identified six studies using the Robson classification within clinical audit cycles to reduce CS rates. All six report reductions in CS rates; however, results should be interpreted with caution because of limited methodological quality. Future trials are needed to evaluate the role of the Robson classification within audit cycles aimed at reducing CS rates.Tweetable Abstract: Use of the Robson classification in clinical audit cycles to reduce caesarean rates. [ABSTRACT FROM AUTHOR]

Objective: Caesarean section was initially performed to save the lives of the mother and/or her baby. Caesarean section rates have risen substantially worldwide over the past decades. In this study, we set out to compile all available caesarean section rates worldwide at the country level, and to identify the appropriate caesarean section rate at the population level associated with the minimal maternal and neonatal mortality.Design: Ecological study using longitudinal data.Setting: Worldwide country-level data.Population: A total of 159 countries were included in the analyses, representing 98.0% of global live births (2005).Methods: Nationally representative caesarean section rates from 2000 to 2012 were compiled. We assessed the relationship between caesarean section rates and mortality outcomes, adjusting for socio-economic development by means of human development index (HDI) using fractional polynomial regression models.Main Outcome Measures: Maternal mortality ratio and neonatal mortality rate.Results: Most countries have experienced increases in caesarean section rate during the study period. In the unadjusted analysis, there was a negative association between caesarean section rates and mortality outcomes for low caesarean section rates, especially among the least developed countries. After adjusting for HDI, this effect was much smaller and was only observed below a caesarean section rate of 5-10%. No important association between the caesarean section rate and maternal and neonatal mortality was observed when the caesarean section rate exceeded 10%.Conclusions: Although caesarean section is an effective intervention to save maternal and infant lives, based on the available ecological evidence, caesarean section rates higher than around 10% at the population level are not associated with decreases in maternal and neonatal mortality rates, and thus may not be necessary to achieve the lowest maternal and neonatal mortality.Tweetable Abstract: The caesarean section rate of around 10% may be the optimal rate to achieve the lowest mortality. [ABSTRACT FROM AUTHOR]

An abstract of the conference paper "Assessment of uterine scar from previous Cesarean section through grey scale histogram" by L. Nardozza and colleagues is presented.