Robson Caesarean section Trends in 21 Countries

Use of the Robson classification to assess caesarean section trends in 21 countries: a secondary analysis of two WHO multicounty surveys

Joshua P Vogel, Ana Pilar Betrán, Nadia Vindevoghel, João Paulo Souza, Maria Regina Torloni, Jun Zhang, Özge Tunçalp, Rintaro Mori, Naho Morisaki, Eduardo Ortiz-Panozo, Bernardo Hernandez, Ricardo Pérez-Cuevas, Zahida Qureshi, A Metin Gülmezoglu, Marleen Temmerman.

WHO Multi-Country Survey on Maternal and Newborn Health Research Network

The crude rate of caesarean section surgery is an important global indicator for measuring access to obstetric services. In many countries (especially high income countries), rates of caesarean section have increased steadily during the past three decades.  The 1985 WHO statement that regional caesarean section rates should not exceed 10–15%3 was based on evidence available at that time; however, the validity of this threshold has since been questioned. Conversely, in many lower-income countries, inadequate access to safe and timely caesarean section is a substantial barrier to improving the outcomes of mothers and neonates.  These nations are often hampered by an absence of reliable epidemiological data about births and mode of delivery. 

The determinants of rising caesarean section trends worldwide are controversial. Some authors have argued that the increase is driven largely by the rising use of no medically indicated caesarean section, which can pose unnecessary risks to mothers and neonates. A deeper understanding of these drivers across countries has been complicated by an absence of international consensus regarding a universal caesarean section classification system. A 2011 systematic review by Torloni and colleagues of 27 caesarean section classification systems identified the ten-group classification system proposed by Robson in 20019 as the most appropriate to compare surgery rates. 

Robson’s system classifies all deliveries into one of ten groups on the basis of five parameters: obstetric history (parity and previous caesarean section), onset of labour (spontaneous, induced, or caesarean section before onset of labour), fetal presentation or lie (cephalic, breech, or transverse), number of neonates, and gestational age (preterm or term; panel 1). The ten Robson categories are mutually exclusive, totally inclusive, and can be applied prospectively, since each woman admitted for delivery can be classified immediately on the basis of a few variables that are generally routinely recorded. This system helps institution-specific monitoring and auditing, and offers a standardised comparison method between institutions, countries, and time points. 

The Robson classification has been used to analyse trends and determinants of caesarean section use in healthcare facilities in both high-income and low-income countries,  and has also been applied to state, national, and international datasets, including data from eight Latin American countries in the WHO Global Survey of Maternal and Perinatal Health. To explore global caesarean section patterns and possible drivers of these trends, we analysed changes in the characteristics of the obstetric populations in two WHO multicounty surveys and used the Robson classification to assess trends in group-specific caesarean section rates and the changes in the absolute and relative contribution of Robson groups to overall caesarean section rates over time.

Full Atricle click here

Original Source THE LANCET Global Health

Safety and Efficacy of Alternative Anitibiotic Regimens

Safety and efficacy of alternative antibiotic regimens compared with 7 day injectable procaine benzylpenicillin and gentamicin for outpatient treatment of neonates and young infants with clinical signs of severe infection when referral is not possible: A randomised, open-label, equivalence trial 

Abdullah H Baqui, Samir K Saha, A S M Nawshad Uddin Ahmed, Mohammad Shahidullah, Iftekhar Quasem, Daniel E Roth, A K M Samsuzzaman, Wazir Ahmed, S M Shahnawaz Bin Tabib, Dipak K Mitra, Nazma Begum, Maksuda Islam, Arif Mahmud, Mohammad Hefzur Rahman, Mamun Ibne Moin, Luke C Mullany, Simon Cousens, Shams El Arifeen, Stephen Wall, Neal Brandes, Mathuram Santosham, Robert E Black.

Projahnmo Study Group in Bangladesh 

Although many developing countries have achieved substantial decreases in deaths in the post-neonatal period and in children aged 1–4 years, neonatal death rates have decreased more slowly, with an estimated 3 million neonatal deaths worldwide every year.  Most of these neonatal deaths are in developing countries, which are characterised by high rates of home delivery by unskilled attendants and high rates of infections in neonates. Up to one in five neonates in developing countries develop life-threatening infections. 

Several preventive interventions against neonatal infections, including tetanus toxoid immunisation of pregnant women, early and exclusive breastfeeding, use of clean delivery practices, and umbilical cord cleansing with chlorhexidine, have been identified and incorporated into many health-care programmes. However, infections remain one of the main causes of neonatal deaths worldwide, accounting for roughly a quarter of neonatal deaths. In settings characterised by high neonatal mortality, the proportion of neonatal deaths caused by infections has been estimated to be up to 50%. Therefore, strategies for timely identification and management of infections in neonates and young infants (aged 0–59 days) are urgently needed. 

WHO recommends that all cases of clinical signs of severe infection in young infants (aged 0–59 days) are treated in hospital with a 7–10 day course of injectable antibiotics-penicillin (or ampicillin) and gentamicin. However, in many low-income and middle-income countries, this care is often not available, accessible, or acceptable to families. Furthermore, the quality of care in peripheral facilities is often inadequate because of scarcity of trained personnel or necessary supplies. These constraints lead to delayed or inadequate treatment or no treatment at all for many young infants in low income and middle-income countries

Strategies for community-based management of infections in young infants by trained community health workers have been developed, assessed, and shown to be effective.10,14–17 In Bangladesh, our group, Projahnmo, showed that identification and treatment of neonates with suspected severe infection by trained community health workers who used injectable procaine benzylpenicillin and gentamicin for 7 days substantially reduced neonatal mortality, compared with no care or untrained care.10 Although treatment of ill neonates by community health workers has been shown to be safe and effective in low-resource settings, major obstacles are associated with large-scale implementation of injectable therapy in the community or at first-level Facilities.

First, difficulties exist in ensuring availability of trained health workers and supplies, and in implementation of quality assurance for safe injectable antibiotic treatment every day for 7–10 days. Second, a 7–10 day regimen of parenteral antibiotic therapy presents challenges to community acceptance and compliance. 

Third, unsupervised use of injections at the community level might be unsafe and could increase the risk of transmission of HIV, hepatitis, and other viral diseases through use of contaminated needles.  Therefore, reduction of the number of injections to be used is important. Furthermore, the justification for 7–10 days of parenteral antibiotic therapy has not been fully established. 7 days of injectable therapy is perceived to be the most efficacious regimen in treatment of severe infections.

However, for some neonates with infections, alternative regimens-eg, those that include a combination of parenteral and oral therapy or that switch to an oral antibiotic after initial treatment with injectable antibiotics for 2–3 days - might be equally effective, as has been shown in older children We aimed to determine whether two antibiotic regimens with a reduced number of injections are equivalent to the standard outpatient course of parenteral antibiotics for the treatment of clinical signs of severe infections in young infants in Bangladesh, whose parents sought care but refused hospital admission.

Full Article click here

Original Source The Lancet Global Health 

Gambia: Bringing Home a New Health Concept

Gambia: Bringing Home a New Health Concept

The Ministry of Health and Social Welfare is rolling out a health concept called HiAPs - Health in All Policies. Recently the ministry, in collaboration with the World Health Organisation (WHO), organised a two-day training session and forum on the implementation of HiAPs.

HiAP was created by the Public Health Institute, the California Department of Public Health, and the American Public Health Association in response to growing interest in using collaborative approaches to improve population health by embedding health considerations into decision-making processes across a broad array of sectors.

HiAPs is a new concept in The Gambia, hence it deserves more promotion and explanation for it to be better understood in our society. HiAPs is a concept that is very essential to government's planning, because it is something actually concerning our health and well-being, the concept takes into consideration the challenges posted by medical interventions and  especially implecations of new medication and its application.

According to our health department and the World Health Organisation (WHO), HiAPs is an approach to public policies, across sectors, which systematically takes into account the health implications of decisions.

Original Source: allAfrica

Full Article: Click Here

Short term exposure to air pollution and stroke

Short term exposure to air pollution and stroke: systematic review and meta-analysis

Anoop S V Shah, , Kuan Ken Lee, , David A McAllister, , Amanda Hunter, Harish Nair, William Whiteley, Jeremy P Langrish, David E Newby, Nicholas L Mills
BMJ 2015

Stroke is a major cause of disability worldwide with an increasing incidence, particularly in low and middle income countries While exposure to outdoor air pollution is strongly associated with acute cardiac events, the relation between air pollution and stroke is less clear

Outdoor air pollution is an important risk factor for cardiovascular disease throughout the world, with particulate air pollution alone responsible for over three million deaths each year. Increases in concentrations of daily air pollution are associated with acute myocardial infarction and admission to hospital or death from heart failure.

These associations could be mediated through direct and indirect effects of exposure to air pollutants on vascular tone, endothelial function, thrombosis, and myocardial ischaemia. Stroke accounts for five million deaths each year and is a major cause of disability.  The incidence of stroke is increasing, particularly in low and middle-income countries, where two thirds of all strokes occur. The global burden of stroke related disability is therefore high and continues to rise. 

This has been primarily attributed to an ageing population in high-income countries and the accumulation of risk factors for stroke, such as smoking, hypertension, and obesity, in low and middle income countries.  The impact of environmental factors on morbidity and mortality from stroke, however, might be important and is less certain. Given similarities in the pathophysiology of acute coronary syndrome and ischaemic stroke, it is plausible that air pollution is also an important and modifiable risk factor.  

To provide global policy makers with the best estimates of the effect of short term exposure to air pollution on risk of stroke, we systematically reviewed studies examining the association between air pollution and admission to hospital for stroke or mortality from stroke.

Open access BMJ

The relation between past exposure to fine particulate air pollution

The relation between past exposure to fine particulate air pollution and prevalent anxiety: observational cohort study

Melinda C Power, Marianthi-Anna Kioumourtzoglou, Jaime E Hart, Olivia I Okereke, Francine Laden, Marc G Weisskopf

BMJ 2015

Toxicological work suggests exposure to particulate air pollution may induce or exacerbate anxiety through increased oxidative stress and systemic inflammation While a small but growing body of literature suggests an association between air pollution and mental health outcomes, including anxiety, data on the relation between exposure to particulate air pollution and anxiety in humans is lacking.

Anxiety disorders, characterized by disruptive fear,  worry, and related behavioral disturbances such as avoidance or physical sensations of hyperarousal,  are the most common type of psychiatric disorder in the general population.  Globally, approximately 16% of people will have an anxiety disorder in their lifetime and 11% will have experienced an anxiety disorder in the past year. 

Anxiety disorders are associated with reduced productivity and increased psychiatric and non-psychiatric medical care, absenteeism, and risk of suicide.  In 2010, anxiety disorders accounted for approximately 26.8 million disability adjusted life years worldwide.  The monetary cost of anxiety disorders is also substantial; in the United States, the annual direct cost of anxiety disorders in the 1990s has been estimated to be $42.3bn (£27.3bn; €37.3bn).  

Women have a higher prevalence of anxiety disorders than men6 and the onset for most anxiety disorders is commonly in adolescence or young adulthood. However, the incidence of anxiety disorders remains substantial in midlife,  and new cases continue to arise into later life,  especially in the case of generalized anxiety disorder. Although numerous pharmacologic and non-pharmacologic therapies are available, remission is not always possible. Many people have persistent symptoms despite use of first line treatments.

Given the substantial personal and societal burden from anxiety and the problem of treatment resistance, it is imperative to identify modifiable risk factors for anxiety disorders and symptoms. One important environmental exposure that may be related to anxiety is air pollution. Specifically, exposure to particulate matter air pollution may induce or exacerbate anxiety through increased oxidative stress and systemic inflammation or through promotion or aggravation of chronic disease.  Though there is a small set of studies considering the association between air pollution and mental health outcomes, we are aware of only two small studies that considered anxiety, and neither looked at total particulate matter. 

The first (n=1002) reported that ozone levels in the prior week were associated with anxiety symptoms, whereas the second (n=100) reported that cumulative exposure to airborne manganese was associated with anxiety symptoms.

Epidemiologic research on the relation between exposure to particulate matter and anxiety is clearly lacking; we evaluated this association in a large prospective cohort study.  Specifically, we hypothesized that higher exposure to particulate matter would be associated with a greater risk of high symptoms of anxiety.  The most biologically relevant period of exposure is currently unknown. 

If particulate matter induces anxiety through chronic oxidative stress, inflammation, or induction of chronic disease, long term cumulative exposure is most likely relevant. If particulate matter aggravates an existing propensity for anxiety symptoms,  through either aggravation of chronic disease or transient changes in oxidative stress or inflammation, exposures closer to the time of symptom assessment may be relevant. 

Therefore, we considered the association between high anxiety symptoms and exposure to particulate matter averaged over five periods prior to the assessment of anxiety symptoms, specified a priori,  ranging from a measure of long term, cumulative exposure  (prior 15 years) to a measure of recent exposure  (prior month).

Open access BMJ

National Conversation on Health Inequalities: Examples of local Practice


National Conversation on Health Inequalities: examples of local practice

Reducing health inequalities: a toolkit and guidance for starting local conversations

The National Conversation on Health Inequalities (NCHI) is a Public Health England programme about reducing differences in health. 

The aim is for local authorities to start talking about health inequalities in their communities.

The NCHI want to together to create a clear, consistent language for describing the causes of health inequalities. By discussing what causes these issues, they can local partners work with communities to plan solutions for change.

National Conversation on Health Inequalities: examples of local practice
NCHI: written and visual examples of local practice

NCHI aims to develop a common language and understanding around health inequalities and, with local partners, encourage and empower local communities to act on them.

The programme launched in 2014 with a toolkit outlining 7 principles for local conversation on health inequalities.

Public Health England (PHE) have since commissioned TNS-BMRB (Taylor Nelson Sofres, British Market Research Bureau) to develop a series of practical written examples of local practice along with video/photo-stories covering:

  • housing
  • employment
  • education
  • communities

National Conversation on Health Inequalities: Video photo stories

This document presents video photo stories that demonstrate how support can help reduce health inequalities.

NCHI commissioned Taylor Nelson Sofres British Market Research Bureau (TNS-BMRB) to produce a series of case studies, including video photo stories.

They illustrate:

  • people’s experiences of health inequalities
  • how support can make a huge difference to social situations and health and wellbeing

Case study
National Conversation on Health Inequalities: the Bromford Deal

This example sets out the work done by the National Conversation on Health Inequalities (NCHI) in supporting tenants into employment.

Saida is a 35 year old parent of 2 teenage children living in a deprived area of the West Midlands. While raising her family she studied at college gaining a diploma in Supporting Teaching and Learning in School, and worked in various administrative support jobs.

Things were looking positive for Saida until her circumstances changed quite abruptly. Sadia had just just started a job as a receptionist and was still in her probation period when she became ill.
She had to have surgery and after the operation she wasn’t able to work for several months. It wasn’t a good impression [to make] and she had to resign.

Having to deal with the surgery and becoming unemployed, Sadia had a death in the family a close member her uncle, then within weeks her aunty also passed.

Once Sadia was fit to return to work, Saida applied for Job Seekers Allowance (JSA) but struggled to find employment. A lack of success in finding work, coupled with unrelated family issues, led to deterioration in her health and wellbeing. 

Sadia wanted to work . But there was a problem, first her health conditions then her family issues and then the death in her family, facing all these issues and problems Sadia applied for jobs and wasn’t receiving any response.
It was very stressfull for Sadia, worrying about the kids, bills, finances, paying rent, everything. 

Sadia was diagnosed with depression and referred for counselling.


Case study
National Conversation on Health Inequalities: Your Activity

This example sets out the work done by the National Conversation on Health Inequalities (NCHI) levelling the playing field in youth sport.

David, a former student at The Carlton Academy, said:

When I first get there on the first lesson and the kids are told; oh you’re doing frisbee today, they always moan, they always say; ‘oh frisbee, it’s just throwing it’, but there’s actually many different things you can do it … it’s beneficial when you actually learn it. It has actually allowed me to participate in sport.

The same old games  
According to the DfE (2013) National Curriculum in England: physical education programmes of study – key stages 3 and 4:

“A high quality physical education curriculum inspires all pupils to succeed and excel in competitive sport and other physically demanding activities.”

Not all students have participated in sport outside of school environments. They can enter school feeling at a disadvantage, which can translate as ‘I am not good at sports’.

Research shows that young people become less engaged in activity between ages 14 and 16, which affects their confidence and competence in being physically active as adults. Jonathon, a former student, said:

“I came out of primary school hating sport and then in Year 9 (secondary school) I played rugby for the first time and absolutely loved it. So, I have a theory there is a sport for everyone, no matter what you say, there is a sport for you.”

Case study
National Conversation on Health Inequalities: Reach Out project

This example sets out the work done by the National Conversation on Health Inequalities (NCHI) using community outreach for better health.

Kerri and Lisa, 2 sisters in their 20s, were living on their own after their parents passed away. Having lost both their parents within a short space of time, the sisters were struggling to cope and had become extremely depressed; both felt unable to leave the house.

Lisa suffered from multiple health conditions including diabetes and a rare skin condition that often left her unable to get up or care for herself. She had developed acute agoraphobia. 

These conditions had gone untreated for at least 18 months. Lisa was consistently refused home visits from her local GP surgery. She could see no way out of their situation and had become suicidal. A Tendring Reach Out Officer said:

“She was very very poorly with diabetes, and she also had another disease – a skin condition which really did disable her, she couldn’t go out, couldn’t move certain days, couldn’t wash herself…she couldn’t even go to the front door. A doctor hadn’t seen her for about a year and a half.”

“With the diabetes situation she was so unwell that she’d asked for a home visit but they’d said ‘no, in your age group, you can come and see us’. She had depression. Her sister had to go out and get the shopping for them.”


Case study
National Conversation on Health Inequalities: Healthy Homes Programme

This example sets out the work done by the National Conversation on Health Inequalities (NCHI) improving homes for better health.

Ann, 62, and her husband Steve, 65, were both ill and finding it difficult to manage at home. Steve had Huntington’s Disease, a degenerative brain disorder and Ann was caring for him.

However, when Ann suffered 2 strokes she needed hospital treatment and there was no one to help Steve. A social worker suggested that Ann arranged respite care for Steve, so that Ann could take a break.

Respite care is short-term accommodation outside the home, where a loved one can be looked after. This provides temporary relief to those caring for family members.

Ann found this very difficult to organise because of her own poor health and negative experiences of respite care for Steve in the past.

Ann said:

“I couldn’t deal with this because of the state I was in…I had 2 mild strokes, so I was in and out of hospital and worried about who was going to look after Steve. I didn’t want to put him back into respite because I had a really bad experience before…I didn’t think he had been cared for properly, and all I wanted to do was to take him home.”

At the time, Steve was confined to the living room at home where he had a hospital bed and a commode because he could not use the stairs safely.

Ann said:

“Because of his condition, the stairs were no good for him and it was clear we needed to live somewhere more accessible. He ended up falling down the stairs and splitting his head open. When he was released from hospital he had 2 care workers getting him up, washing him, getting him dressed, feeding him and returning him to bed. I would have done it.”

Air pollution, stroke and anxiety

Air pollution, stroke and anxiety
bmj 2015)

Particulate air pollution is an emerging risk factor for an increasing number of common conditions

The effects of air pollution on the lungs and heart are now widely appreciated, with expanding evidence for an important role in cardiac disease. The Global Burden of Disease Study identified fine particulate matter (PM2.5) in outdoor air and household air pollution from use of solid fuels as the ninth and fourth leading risk factors, respectively, for disease worldwide and the World Health Organization attributes one in every eight deaths to air pollution.  The effects of air pollution are not limited to cardiopulmonary diseases. Recent evidence suggests a role in diverse outcomes, including diabetes, low birth weight, and preterm birth.

This research stems from improved understanding of the role of air pollution in initiating systemic inflammation, a response that may affect multiple organ systems. 

Two linked studies 

Systematic review and meta-analysis 
The relation between past exposure to fine particulate air pollution 

add to growing evidence that air pollution is an important risk factor for an increasing number of common diseases.

Paywall BMJ

Health and Wellness Impact: Model for Healthcare Design

Health and Wellness Impact: Integrative Model for Healthcare Design

The ASID and IDC Impact Summit 2015: Health &  Wellness in the Built Environment at Lake Nona Medical City in Orlando, it has become clear additional focus on a collaborative approach to programming,  planning,  and design  are more essential than ever to create a successful solution. 

Often health and wellness has been evaluated as a separate component of the designed physical environment. 

However, in utilizing a framework that evaluates several design considerations, there are many commonalities that also include health and wellness as a desired outcome when utilizing an evidence-based design approach.

Expanding on the concept of health and well-being, the WELL Building Standard has gained traction within the design community. 

The goal of this standard is to focus on human health and wellness, based on a body of medical research that evaluates the connection between the built environment and its impacts on occupants.

In evaluating the seven areas of consideration 

  • air
  • water
  • nourishment
  • light
  • fitness
  • comfort
  • mind

The Green Globes Continual Improvement for Existing Buildings for Healthcare (CIEB-HC) also addresses many of the same topics that are outlined in the WELL Building Standard. 

In evaluating different rating systems, guidelines, and building and licensing codes, there are many commonalities among them, so it is recommended to evaluate design considerations right from the beginning of a project process.

For healthcare projects, this is called the functional programming process and the design considerations include:

  • Establishing the care model and intended care population
  • Sustainability goals
  • Resilience needs based upon region 
  • Operational needs, circulation, and service delivery 
  • Risk and safety assessments 
  • Establishing desired staff, patient, resident, and visitor outcomes
  • The environment of care, including evaluation of access to nature and views
  • Health and well-being goals
  • Benchmarking and performance improvement goals

By establishing these design considerations right from the start, it is possible to lay out a research agenda that will inform decisions to be made regarding these elements, and support decisions that maximize the potential of positive outcomes. 

Original source Interiors & Sources

Fifth Regional Seminar on Active Travel

Fifth Regional Seminar on Active Travel

Active Travel – Better Towns Ride the Lights, Walk the Prom
co-hosted by Living Streets and North West Active Travel Network

Venue: The Solaris Centre, Blackpool

Wednesday 14 October 2015

The Speakers will include

Nick Davies (University of Central Lancashire) Economic benefits of active travel
Nick Cavill (Consultant) Health benefits of active travel
Tom Platt (Head of Policy, Living Streets) Walkable places – Current developments
Karen Stevens (Liverpool City Council) Bike Hire Schemes
Andy Howard (Transport for Greater Manchester) CCAG – Towards Velocity 2025
Jon Little (Waltham Forest Council) The Waltham Forrest Mini-Holland
Steve Essex (Transport Initiatives) Pedestrian-cycle interactions
Latif Patel (Blackpool Council) Crossings and signals phases at junction

Prior to the formal programme optional cycling and walking tours will be available from Blackpool North Station visiting sites of special traffic interest en route to the Solaris Centre

Lunch will be provided by Café Chicco at the Solaris Centre.


Standard: £50
Representatives of voluntary bodies: £25

Bookings can be registered at :

Deadline: Monday 5th October



When, how and why unemployment insurance influences health

Social welfare matters: A realist review of when, how, and why unemployment insurance impacts poverty and health

Patricia O'Campoa, Agnes Molnara, Edwin Nga, Emilie Renahya, Christiane Mitchella, Ketan Shankardassa, Alexander St. Johna, Clare Bambrae, Carles Muntanera
Social Science & Medicine Volume 132, May 2015


  • Studies from 2000 to 2013 on unemployment insurance in various countries were reviewed.
  • Unemployment insurance protects health through material and psychological mechanisms.
  • Unemployment insurance generosity can moderate harmful consequences of being jobless.
  • Generous insurance benefits protect the psychological health of employed and unemployed.


Full article: Click here (Open Access)
Original source: ScienceDirect

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Health and Transportation: Small scale area association

Health and transportation: Small scale area association
Mehran Fasihozaman Langerudi, Mohammadian Abolfazl (Kouros), P.S. Sriraj
Journal of Transport & Health Volume 2, Issue 2, June 2015


  • A methodology is developed to disaggregate county-level health data.
  • We have proposed built environment-related individual health condition models.
  • Iterative Proportional Fitting (IPF) approach can be used to disaggregate different data sources.


Public health, as a major factor influencing the livability and well-being of a community has been a subject of interest in many academic fields. It is postulated that public health has strong correlations with various factors including land development, urban form, and transportation system elements. However, due to scarcity of individual level and confidential health data, such analysis has been typically conducted in an aggregate level resulting in less accurate results due to aggregation bias. In this paper, a methodology is developed and applied to disaggregate an individual-level health data in county scale into smaller geography by using an iterative proportional fitting approach while maintaining the marginal distributions of the controlled variables. Then, the disaggregated data is used to estimate various models of individual health condition as a function of socio-demographic, built environment, and transportation system attributes. It is noteworthy that the proposed approach can be applied to disaggregate any aggregate data in an efficient way.

Full Article: Click here (Paywall)

Original source: SPAHG

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