![]() ![]() Women were categorized into 10 groups according to the RTGCS. 48 women with missing medical records, 41 women with second trimester abortion, 14 women without the mode of delivery and 1 woman without neonatal birth weight were excluded from analysis. To make our findings comparable to other studies, we restricted the analysis to births more than 24 gestational weeks or birth weight more than 500 g, including all live births, stillbirth and fetal deaths and second trimester abortion. Detailed information on maternal demographic characteristics, prenatal history, labor and delivery, and neonatal conditions was recorded. Trained medical students carried out the data abstraction. A weight using an inverse probability weighting method was assigned to each woman. These deliveries represented the total births during that period. A total of 10,855 deliveries were selected. Either electronic or paper medical records were retrieved and relevant information was extracted. A predetermined percentage of records were randomly selected by using computer-generated random digits. In each hospital, a list of all eligible deliveries within the study period was generated from the hospital information system. Since the number of annual deliveries in each hospital varied greatly, from around 1,000 to nearly 20,000 births a year, to ensure the precision of the CS rate estimates in each hospital, in hospitals that had an annual delivery volume below 10,000 births, 20% of the total births were randomly selected while in hospitals with more than 10,000 births a year, 10% of the total births were randomly selected. A total of 62,653 births were delivered in these hospitals from Januto June 30 2016. ![]() These hospitals delivered approximately half of all births in Shanghai. Primary care hospitals were not included in the present study, as they usually do not provide obstetric services. We selected top 20 hospitals based on the annual delivery volume, including 3 tertiary maternity hospitals, 6 secondary maternity hospitals, 4 tertiary general hospitals and 7 secondary general hospitals across Shanghai in 2016 (Fig. There are 79 hospitals that provide delivery services in Shanghai right now. Findings of this study may help develop strategies to reduce CS rate in China. Due to the important role of birth weight in mode of delivery 5, we also analyzed the mode of delivery according to birth-weight category by RTGCS. In this study, we used RTGCS to classify pregnant women into subgroups and compared the CS rate by different hospital types and subgroups. It also enables comparisons between different districts and institutions. The RTGCS is a simple and reliable delivery classification system that has gained wide acceptance by the international obstetric and midwifery community 4. It classifies all deliveries into one of ten groups based on five basic parameters 3: obstetric history, onset of labor, fetal lie, number of fetuses, and gestational age. The Robson Ten-Group Classification System (RTGCS) offers a useful tool to dissect the overall CS rate and facilitate the understanding of the components. However, large obstetric databases with reliable and sufficient details are still rarely available in most parts of China to understand the variation in CS rate among hospitals and the causes for a very high overall CS rate. Repeat CS may even increase the overall CS rate in the near future. On the other hand, the very high CS rate in earlier years had resulted in a high proportion of multiparous women with a scarred uterus. On one hand, nulliparous women may be more inclined than before to have a vaginal birth with consideration of having a second child later. With the adoption of two-child family policy in China, how the CS rate may change remains unclear. For example, in Shanghai, the CS rate reached its peak at 60.9% in 2008 and declined to 50.8% in 2014 2. However, the CS rates in urban settings of China are much higher than the national average and have changed in a different pattern. A recent large scale study showed that the overall CS rate in China increased from 28.8% in 2008 to 34.9% in 2014 2. The cesarean section (CS) rate has been rising worldwide over the last two to three decades 1. ![]()
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