European Journal of Cardiovascular Medicine

The global prevalence of cesarean section deliveries has witnessed a significant upward trend over the past few decades¹. While this surgical intervention is indispensable in situations where vaginal delivery is unfeasible or contraindicated, potentially safeguarding the lives of both mother and fetus, it is noteworthy that cesarean sections are sometimes performed without clear medical necessity or based on ambiguous indications such as obstructed labor with intact membranes². Although cesarean sections are widely regarded as life-saving procedures, they are not without risks for both the mother and the neonate, impacting not only the current pregnancy but also future gestations.

The spectrum of complications associated with cesarean sections is broad and significant. These include elevated risks of maternal morbidity and mortality, increased likelihood of blood transfusion requirements, extended hospital stays, postpartum infections, retained placenta, stillbirth, and postpartum hemorrhage. Given these potential adverse outcomes, it is imperative that each case be meticulously evaluated before opting for a cesarean section. This careful assessment serves a dual purpose: to prevent unnecessary exposure to complications in cases where the procedure may not be essential, and to ensure that women who genuinely require a cesarean section are accurately identified and provided with this crucial intervention. This balanced approach is fundamental in optimizing maternal and neonatal outcomes in obstetric care.

In the contemporary obstetric landscape, the paramount challenge lies in maintaining a low cesarean section rate while simultaneously ensuring the safety of both mother and newborn. This delicate balance necessitates ongoing audits of cesarean sections performed in healthcare settings. Among the various classification systems employed for this purpose, three have gained prominence: those based on primary clinical indications, those categorizing the degree of urgency or absolute need for cesarean delivery, and the Robson classification. A comprehensive systematic review conducted by Torloni MR et al. evaluated these different classification systems, ultimately concluding that Robson's 10 Groups classification emerged as the optimal framework for monitoring cesarean sections.

The World Health Organization has subsequently endorsed the Robson classification as the "Global standard" tool for monitoring cesarean sections, further solidifying its importance in obstetric practice. This classification system, also known as the Ten Group Classification System (TGCS), stratifies cesarean sections into ten distinct groups based on various parameters including the nature of the pregnancy, past obstetrical history, the progression of labor and delivery, and the gestational age of the woman.

Given the persistent upward trend in cesarean section rates globally, this study aims to employ the Robson classification to analyze cesarean sections within our specific healthcare context. The primary objectives are twofold: to evaluate the relevance and applicability of this classification system in our setting, and to formulate strategic interventions aimed at curbing cesarean section rates, with a particular focus on primiparous women. This approach aligns with the broader goal of optimizing maternal and neonatal outcomes while addressing the growing concerns surrounding the overutilization of cesarean deliveries.

This retrospective analysis encompassed 458 consecutive cesarean sections performed between March 2023 and February 2024 at the Department of Obstetrics and Gynaecology, National Institute of Medical Sciences Jaipur, Rajasthan. The study protocol involved the systematic retrieval and documentation of relevant data using a structured proforma.

Data Collection and Statistical Analysis

The data collection process was comprehensive, drawing from the labour room birth register, which was meticulously maintained with regular monthly and annual censuses. All variables essential for the application of Robson's classification were systematically collected and recorded.

The statistical analysis employed standard statistical formulas to process and interpret the collected data. All statistical analysis is performed in SPSS (statistical package for social sciences) version 23, Microsoft Word and Microsoft Excel software. The correlation graph is made from the Loggerpro version 3.16.2.

A total number of women delivered during this period were 1133. The total number of caesarean sections were 458. So, the overall Caesarean section rate over the given time period was 40.42%.

In our study Robson Groups 1 to 5 contributed the most to the study population (74%) while the groups 6 to 10 contributed only 26%.

Contribution (Table 3) to total caesarean section rates was highest in group 5 followed by group 1. Percentage wise Group 9 had the greatest i.e., 100% Caesarean section rates. This means that all the women in this group got delivered by caesarean sections followed by Group 6 (93%) and Group 5 ( 92%). Groups 3 and 2 had the least section rates, i.e., 6% and 15% respectively, which means that most women in these groups got delivered vaginally (Table 6).

The caesarean section rate at our hospital stands at 40.42%, significantly higher than the 10% threshold proposed by the World Health Organization as optimal for reducing maternal and newborn mortality rates. This elevated rate can be attributed to our institution's status as a tertiary care and referral center, which routinely receives complex pregnancy cases from peripheral facilities, often necessitating caesarean deliveries. To address this high rate, implementing regular antenatal check-ups, raising awareness about high-risk factors, and ensuring prompt interventions could prove beneficial in reducing caesarean section rates.

Robson's Group 5 emerges as the most significant contributor to overall caesarean section rates, underscoring the need for comprehensive counseling regarding vaginal birth after caesarean (VBAC). Incorporating trials of labor after caesarean section into routine obstetric practice for selected low-risk cases could help mitigate this trend. Group 1 represents the second-largest contributor, primarily due to the referral of cases with clear indications for caesarean section already in spontaneous labor. Group 10 ranks third in contribution, a consequence of our well-equipped Neonatal Intensive Care Unit attracting preterm labor cases from other facilities.

The presence of a reproductive medicine department offering infertility treatments also influences caesarean section rates, particularly in Group 2, as these precious pregnancies are often delivered via caesarean section. Comparative studies support our findings: Spandan et al. reported an overall caesarean section rate of 50.47%, with major contributions from Groups 5 (18.10%), 2 (13.96%), and 1 (5.97%)⁴. Gomathy E et al. similarly found Group 5 (9.24%) as the highest contributor, followed by Groups 2 (6.21%) and 1 (6.06%)⁵. Shanti Sah et al.'s study aligns with ours, identifying Group 5 (9.26%) and Group 1 (7.27%) as the primary contributors⁶. Dhodapkar SB et al. reported an overall rate of 32.6%, with Group 5 (40.1%) and Group 1 (24.0%) as the main contributors⁷. Chong C et al.'s research highlighted that multiparous women with a previous caesarean birth (Group 5) and nulliparous women with singleton pregnancies in spontaneous labor (Group 1) were responsible for 75% of the increase in caesarean section rates from 2000 to 2010⁸.

This study's primary strength lies in its application of the Ten Group Classification System (TGCS) to analyze caesarean section trends at our institution, providing valuable insights into local obstetric practices. However, the study's generalizability is constrained by its single-center design and relatively limited sample size, which may not fully represent broader population trends.

The Robson's Ten Group Classification revealed that Groups 5 and 1 were the most significant contributors to caesarean deliveries in our study population. Previous caesarean section and fetal distress emerged as the predominant indications for surgical intervention.

These findings align with research conducted by Kant A et al., which reported a caesarean section rate of 18.4% for Group 1, with a relative group size of 21.4% and a 7.34% contribution to the overall caesarean section rate[1]. The variability in results across studies employing Robson's classification underscores a key limitation of this system: its outcomes are context-dependent, influenced by the specific study population and institutional characteristics, precluding broad generalization.

Despite these limitations, the Robson classification remains a valuable tool for assessing caesarean section patterns. Moving forward, it is imperative to ensure that caesarean sections are performed judiciously, strictly adhering to clinical indications to optimize maternal and neonatal outcomes.

1. Betran AP, Ye J, Moller AB, Zhang J, Gulmezoglu AM, Torloni MR. The increasing trend in caesarean section rates: global, regional and national estimates: 1990-2014. PLoS One. 2016;11:e0148343.
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3. WHO statement on caesarean section rates. Reprod Health Matters. 2015;23:149-150.
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