OBJECTIVE: To determine risk factors associated with cesarean delivery among nulliparous women in spontaneous labor with a single, cephalic, term pregnancy (Robson group 1). METHODS: Data were assessed from the WHO Global Survey of Maternal and Perinatal Health conducted in 2004-2008. RESULTS: Among 82 280 women in Robson group 1, 67 698 (82.3%) had vaginal and 14 578 (17.7%) had cesarean delivery. In adjusted analyses, maternal factors associated with cesarean included age older than 18 years, being overweight or obese, being married or cohabitating, attending four prenatal visits or more, and being medically high risk (P<0.001). Women who were obstetrically high risk, referred during labor, or at 39 gestational weeks or more were also more likely to undergo cesarean (all P<0.001). Facility-level factors associated with cesarean were availability of an anesthesia service 24/7, being a teaching facility, requirement of fees for cesarean, availability of electronic fetal monitoring, and having providers skilled in operative vaginal delivery (all P<0.01). CONCLUSION: The analysis highlights the importance of maintaining a healthy pre-pregnancy and pregnancy weight, optimizing management of women with medical problems, and ensuring clear referral mechanisms for women with intrapartum complications. The association between fees and cesarean delivery warrants further exploration.
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