European Journal of Cardiovascular Medicine

The escalating rates of cesarean sections (CS) globally have prompted concerns regarding maternal and neonatal outcomes, particularly when CS rates exceed 10% ^[1,2]. While CS can be life-saving in situations where vaginal delivery is contraindicated, their overuse or performance without clear indications poses significant risks ^[3]. These risks encompass short and long-term complications, ranging from maternal morbidity to increased mortality rates, necessitating a careful balance between benefits and risks, prioritizing the well-being of both mother and child ^[4-6].

In India, where institutional delivery rates are high, regional disparities and socioeconomic factors contribute to varying CS rates, potentially leading to both overutilization and underutilization of this intervention ^[7]. Rural areas often lack access to adequately equipped health facilities, exacerbating maternal mortality and complications ^[8]. Thus, ensuring optimal CS rates while safeguarding maternal and neonatal safety presents a considerable challenge

To address this challenge, continuous auditing of CS rates is essential. The World Health Organization (WHO) recommends Robson's classification, also known as the Ten-Group Classification System (TGCS), as a global standard for monitoring CS rates ^[9]. This classification system categorizes CS into ten groups based on pregnancy characteristics, obstetric history, labor progression, and gestational age.

Despite numerous studies on CS standardization and classification, including notable works by Prameela et al., a research gap persists in the Central Vindhya region regarding CS rates based on Robson's classification ^[10]. Hence, this study aims to fill this gap by identifying the clinically relevant groups contributing most to CS deliveries in this region. By elucidating the specific groups driving CS rates, this research seeks to inform targeted interventions aimed at optimizing CS utilization while ensuring maternal and neonatal safety.

Study Design: This cross-sectional study was conducted at the Department of Obstetrics and Gynaecology, S.S. Medical College, Rewa, Madhya Pradesh, India. Approval from the 9institutional ethics committee was exempted as this was a record-based study.*

Study Center: S.S. Medical College is a prominent tertiary referral hospital affiliated with Madhya Pradesh Medical Sciences University, Jabalpur. The hospital handles approximately 10,000 to 11,000 deliveries annually, catering to both referred and admitted cases with varying degrees of complications.

Study Population: The study population comprised 7,484 women who underwent cesarean sections (CS) at or beyond 28 weeks of gestation in the hospital over a specified 3-year period from January 2020- Dec 2022.

Inclusion Criteria: Women with onset of labor (spontaneous, induced, or planned CS), singleton or multiple pregnancies, fetal presentation (cephalic, breech, or abnormal lie), and parity (with or without previous cesarean) were included.

Exclusion Criteria: Term or preterm normal or instrumental deliveries, as well as cases of laparotomy for uterine rupture, were excluded from the study.

Data Collection: Patient data were retrieved from various hospital registers, including the labor number register, maternity OT register, admission register, and discharge register. These registers contain comprehensive information about all women who delivered in the hospital, irrespective of the mode of delivery.

Statistical Analysis: All collected data were recorded on a predesigned proforma, including demographic details, maternal history, pregnancy-related information (parity, gestational age, fetal presentation, number of fetuses, onset of labor), management outcomes, and maternal and fetal outcomes at discharge (complications, birth weight). Data analysis was performed using simple statistical methods, such as percentages and proportions.

RESULTS:

During the specified time period, a total of 26,552 deliveries were conducted at the hospital, out of which 7,484 were delivered by cesarean section (CS), resulting in a CS rate of 28.18%. Table 1 summarizes the characteristics of the study participants, including age distribution, area of residence, gravidity, gestational age, history of previous cesarean delivery, fetal presentation, number of fetuses, onset of labor, fetal outcome, and birth weight distribution.

Table 1: Robson’s classification

Table 2: Characteristics of Study Participants

The highest contribution to CS was observed in Robson's group 5 (multiparous with prior cesarean section, singleton, cephalic, >37 weeks), accounting for 32.58%, followed by group 1 (nulliparous, singleton, cephalic, term in spontaneous labor) and group 2 (nulliparous, singleton, cephalic, term induced or cesarean before labor) with contributions of 22.45% and 12.25%, respectively.

Additionally, 6.44% of CS cases belonged to group 6 (all nulliparous breech), while CS rates in group 3 (multiparous without previous cesarean, singleton, cephalic term in spontaneous labor) and group 4 (multiparous without previous cesarean, singleton, cephalic, term induced or cesarean before labor) were 4.81% and 4.20%, respectively. Furthermore, CS rates in groups 10 (singleton, cephalic, <37 weeks including previous cesarean sections) and 7 (all multiparous breech) were 3.70% and 2.75%, respectively. CS rates were lowest in group 8 (all multiple pregnancies including previous CS) at 1.45%. Table 2 present the distribution of CS according to Robson's groups.

Table 3: Categorization of Cesarean Sections According to Robson's Classification

Indications leading to cesarean sections are detailed in Table 4, with previous cesarean section being the most common indication (32.57%), followed by fetal distress (16.56%) and meconium-stained liquor (19.2%).

Table 4: Indications for caesarean sections

These results provide insights into the distribution of cesarean sections according to Robson's classification and highlight the prevalence of various indications leading to cesarean deliveries in the study population.

The results of this study provide valuable insights into the patterns of cesarean section (CS) utilization and associated factors in the Central Vindhya region, contributing to the broader discourse on obstetric care and maternal health outcomes. Our findings underscore the multifaceted nature of CS rates, influenced by a combination of clinical, demographic, and institutional factors.

The observed CS rate of 28.18% aligns with global trends of increasing CS rates, reflecting a complex interplay of medical, social, and cultural factors ^[11]. Notably, Robson's classification revealed that multiparous women with prior cesarean sections (Robson's group 5) constituted the largest proportion of CS cases, emphasizing the impact of obstetric history on delivery mode decisions ^[12]. Similarly, nulliparous women in spontaneous labor (group 1) and those with induced labor or cesarean before labor (group 2) contributed significantly to CS rates, highlighting the importance of labor progression and management strategies in obstetric care ^[13].

Our findings also shed light on demographic disparities in CS rates, with primigravida women comprising a significant proportion of the study population. This demographic subgroup may require tailored approaches to address unique obstetric needs and minimize unnecessary interventions ^[14]. Moreover, the prevalence of indications such as fetal distress, meconium-stained liquor, and failed medical induction underscores the complexity of decision-making in obstetric practice and the need for vigilant monitoring to ensure timely interventions ^[15].

The high proportion of CS cases attributed to previous cesarean sections underscores the importance of appropriate management strategies for vaginal birth after cesarean (VBAC) and efforts to prevent primary cesarean deliveries. Evidence-based guidelines and multidisciplinary approaches are essential to optimize VBAC rates and reduce the burden of repeat cesarean deliveries ^[16].

Recent studies have emphasized the role of shared decision-making and patient-centered care in obstetric practice, highlighting the need for informed discussions about the risks and benefits of cesarean delivery [17]. Additionally, interventions aimed at promoting vaginal birth, such as labor support, continuous fetal monitoring, and non-pharmacological pain management strategies, may help reduce CS rates and improve maternal and neonatal outcomes ^[18].

Limitations of study: This study includes the retrospective design, reliance on hospital records, and potential for underreporting or misclassification of CS indications. Future research endeavors should focus on prospective studies, qualitative investigations, and implementation research to identify effective strategies for reducing CS rates and improving maternal health outcomes in resource-limited settings.

The study contributes to the growing body of evidence on CS utilization and underscores the need for context-specific interventions to optimize obstetric care and ensure safe and equitable outcomes for mothers and newborns in the Central Vindhya region

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