OBJECTIVE: To assess changes in caesarean section (CS) rates in Europe from 2015 to 2019 and utilise the Robson Ten Group Classification System (TGCS) to evaluate the contribution of different obstetric populations to overall CS rates and trends. DESIGN: Observational study utilising routine birth registry data. SETTING: A total of 28 European countries. POPULATION: Births at ≥22 weeks of gestation in 2015 and 2019. METHODS: Using a federated model, individual-level data from routine sources in each country were formatted to a common data model and transformed into anonymised, aggregated data. MAIN OUTCOME MEASURES: By country: overall CS rate. For TGCS groups (by country): CS rate, relative size, relative and absolute contribution to overall CS rate. RESULTS: Among the 28 European countries, both the CS rates (2015, 16.0%-55.9%; 2019, 16.0%-52.2%) and the trends varied (from -3.7% to +4.7%, with decreased rates in nine countries, maintained rates in seven countries (≤ ± 0.2) and with increasing rates in 12 countries). Using the TGCS (for 17 countries), in most countries labour induction increased (groups 2a and 4a), whereas multiple pregnancies (group 8) decreased. In countries with decreasing overall CS rates, CS tended to decrease across all TGCS groups, whereas in countries with increasing rates, CS tended to increase in most groups. In countries with the greatest increase in CS rates (>1%), the absolute contributions of groups 1 (nulliparous term cephalic singletons, spontaneous labour), 2a and 4a (induction of labour), 2b and 4b (prelabour CS) and 10 (preterm cephalic singletons) to the overall CS rate tended to increase. CONCLUSIONS: The TGCS shows varying CS trends and rates among countries of Europe. Comparisons between European countries, particularly those with differing trends, could provide insight into strategies to reduce CS without clinical indication.

3rd Medical School of Charles University Prague Czech Republic

Department of Epidemiology and Biostatistics Institute of Mother and Child Warsaw Poland

Department of Obstetrics and Gynaecology University Medical Centre Ljubljana Slovenia

Department of Obstetrics and Gynecology Division of Obstetrics and Feto Maternal Medicine Medical University of Vienna Vienna Austria

Faculty of Medicine East European Institute for Reproductive Health Academy of Romanian Scientists University 'Ovidius' Constanţa Constanța Romania

Health Monitoring Unit Ministry of Health Nicosia Cyprus

Institute for Quality Assurance and Transparency in Healthcare Berlin Germany

Institute for the Care of Mother and Child Prague Czech Republic

Institution of Health Science Research University of Akureyri Akureyri Iceland

National Centre for Disease Prevention and Health Promotion Istituto Superiore di Sanità Italian Ministry of Health Rome Italy

Nursing Department School of Medicine Autonomous University of Madrid Madrid Spain

Perinatal Epidemiology and Reproductive Health Unit CR2 School of Public Health Université Libre de Bruxelles Brussels Belgium

The Centre for Disease Prevention and Control of Latvia Riga Latvia

Université de Paris Cité Épidémiologie Obstétricale Périnatale et Pédiatrique INSERM U1153 INRA Paris France

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