Analysis of Cesarean Section rate in Minia University Maternity Hospital using Robson ten Group Classification System (A retrospective study}

Conclusion

The study highlights a high CS rate, driven predominantly by Group 5. Robson classification proved valuable in identifying target areas for intervention. Strategic efforts are needed to reduce primary CS and support VBAC to control the growing trend of cesarean deliveries.

Introduction

Cesarean section (CS) rates vary significantly worldwide, ranging from as low as 0.4% to over 50%, and have steadily increased over the past three decades ⁽¹⁾. Efforts to determine the optimal CS rate have used different approaches, with one of the earliest and most influential being the WHO’s 1985 recommen-dation of a maximum rate of 15%⁽²⁾.. This figure was based on rates observed in countries with the lowest maternal and neonatal mortality, adjusted for high-risk populations in low- and middle-income settings ^(3).

CS is performed to prevent or manage serious maternal or neonatal complications. Ideally, the CS rate should correspond to the lowest possible maternal and perinatal morbidity and mortality. However, studies mainly from high-income countries have reported either no significant association between CS rates and health outcomes ⁽⁴⁾ or only modest correlations in specific subgroups ⁽⁵⁾. International research comparing health outcomes across diverse settings remains limited ^(6).

The optimal CS rate likely varies across populations, depending on the proportion of high-risk pregnancies. Some studies have attempted to adjust for case mix, but large-scale, comparative international data are still lacking. A more effective strategy may involve identifying which groups of women contribute most to rising CS rates, enabling targeted clinical and policy interventions. ^(6).

In 2011, a WHO review recommended the Robson classification as the best method for analyzing and comparing CS rates ⁽⁷⁾. It categorizes all women into ten groups based on six obstetric factors: parity, previous CS, gestational age, onset of labor, fetal presentation, and number of fetuses. Each woman fits into one group only, making the system simple, consistent, and suitable for monitoring trends. ^(8).

Due to its clinical relevance and global applicability, the Robson classification has been adopted widely and endorsed by the WHO for routine use in evaluating and optimizing CS practices ^(9).

Patients and Methods

I- Study Design and Setting:

This is aretrospective cross-sectional study that was conducted at Minia Maternity University Hospital between January 2022 and December 2023.

II- Ethical Approval:

Approval was obtained from the Ethical Committee of the Department of Obstetrics and Gynecology, Faculty of Medicine, Minia University, on 26 May 2024.

III- Study Population and Inclusion Criteria:

A total of 8,266 women who have been delivered at ≥ 28 weeks of gestation and/or with a birth weight ≥ 1000 g during the study period were included. The study population comprised women who gave birth to a live newborn meeting these criteria. Each woman was classified into one of the ten Robson groups according to six obstetric variables: parity, previous cesarean section, gestational age, onset of labor, number of fetuses, and fetal presentation.

IV- Exclusion criteria:

All women who delivered at ≤ 28 weeks of gestation and/or with a birth weight ≤ 1000 g during the study period were included.

V- Equipment: All informations were perfo-rmed with a scanner.

VI- Study design:  Background Information was reported as:

Maternal age, Obstetric risk (as Preexisting medical condition, Preeclampsia, GDM, IUGR, Infection, Placenta abruption, Placenta previa).

Core variables for Robson classification:

Parity, Previous CS, Onset of labour, Number of fetuses, Presentation, Gestational age, Mode of delivery and Primary Indication for CS. Then Groups were assigned as:1, 2, 3, 4, 5, 6,7 ,8 ,9 10

VII- Data analysis:

Data were collected from hospital records using a predesigned form. The collected data were verified and coded by the researcher, then entered and analyzed using SPSS version 21. Graphics were created using Microsoft Excel. Quantitative data were presented as mean and standard deviation, while qualitative data were presented as frequency distribution. The association between Robson classification and maternal characteristics was assessed using Fisher’s exact test and one-way ANOVA test.

A p-value less than 0.05 was considered statistically significant.

Results

A total of 8,266 deliveries were included in the analysis. The mean maternal age was 30.9 ± 7.7 years. Multiparous women constituted 89.8% of the sample, and 55.9% had a previous CS. Multiple pregnancy were noted in 4.8% of cases.

According to RTGCS:

Group 5 was the largest contributor to the CS rate (55.9%).

Group 10 accounted for 22.6%.

Group 2 contributed 6.1%.

A statistically significant association was found between Robson group classification and maternal age, parity, gravidity, gestational age, labor status, previous CS, and fetal presentation (p < 0.0001).

Discussion

The Robson Ten Group Classification System (RTGCS) is a globally recognized tool endorsed by the World Health Organization for the standardized analysis of cesarean section (CS) rates^[13,14]. It categorizes all deliveries into ten mutually exclusive and totally inclusive groups based on six key obstetric variables: parity, previous CS, gestational age, onset of labor, fetal presentation, and number of fetuses^[8]. This approach allows for consistent comparisons across time, institutions, and regions regardless of clinical settings or case mix ^[10]. Its simplicity and clarity have made it the preferred system for identifying specific population groups contributing most to rising CS rates, facilitating targeted clinical audits and interventions ^[9].

Numerous studies have applied the RTGCS in both high- and low-income settings, demon-strating its utility in highlighting preventable contributors to CS rates^[15]. In Egypt, where CS rates have exceeded 50% nationally^[11], appli-cation of the Robson system is especially critical. The classification helps distinguish between medically indicated and potentially avoidable CS, and promotes the adoption of evidence-based practices, such as supporting vaginal birth after cesarean (VBAC) in appropriate cases ^[21].

Thus, its application at Minia Maternity and Child Hospital provides an essential framework for both internal quality monitoring and international benchmarking.

In our study, clinical data (Table 1) showed that the mean age of of a total 8,266 patients was 30.9 ± 7.7 years, and most were multigravida (89.8%) and multiparous (mean parity 2.2 ± 1.3). These factors may have contributed to the high representation of Groups 3 to 5 in our cohort. In addition, multiple pregnancies represented 4.8% of cases and were entirely classified under Group 8, while breech presentations appeared exclusively in Groups 6 and 7, and abnormal lie in Group 9.

In the present study conducted at Minia Maternity and Child Hospital, 8,266 of a total 15,182deliveries were recorded during the study period, with a cesarean section (CS) rate of 54.4%. The highest cesarean section rate was observed in Group 5 (multiparous women with at least one previous CS, single cephalic fetus, ≥37 weeks), which alone contributed 55.9% of all CS cases (figure 1). This aligns with findings from multiple Egyptian centers such as Al-Azhar Damietta (56.7%) and Benha University Hospitals^[16,17]. Similarly, the Assiut University Hospital study also identified Group 5 as the leading contributor ^[18].

Internationally, Group 5 is also a major contributor, representing 38.8% in Portugal and 35.4% in Germany ^{[19, 20].} The consistently high CS rate in this group highlights a global challenge in managing repeat cesarean deliveries, often stemming from reduced implementation of VBAC protocols ^[21]. Promoting safe VBAC and improving patient counseling could significantly impact this group and reduce overall CS rates. However, countries like the Netherlands and Sweden have reported lower contributions from Group 5 due to the successful implementation of structured VBAC programs and support for trial of labor after cesarean (ToLAC) ^[22].

The second most contributing group in our study was Group 10 (singleton cephalic preterm pregnancies), accounting for 22.6% of all CSs (figure 1). This is notably higher than interna-tional averages and suggests a local burden of high-risk preterm conditions requiring early intervention. Common indications in this group included intrauterine growth restriction (IUGR), abnormal Doppler findings, preterm premature rupture of membranes (PPROM), oligohydramnios, non-reassuring CTG, and hypertensive disorders of pregnancy. These findings underscore the need for improved antenatal surveillance and timely referrals to mitigate emergency CS in this vulnerable population.

Internationally, second contributors vary. While Group 10 ranks second in our study, other countries report different patterns. For example, in Italy and France, Group 2 (nulliparous women undergoing induction or pre-labor CS) often shows a higher CS contribution due to increasing elective cesar-eans and inductions without medical indications _[20]. This contrast highlights the influence of healthcare policies and obstetric practices on CS distribution across Robson groups.

In analyzing the clinical data from our study, we observed no significant association between the Robson groups and maternal characteristics and age, but significant association regarding parity, gravidity, gestational age, labor onset, previous CS, multiple gestation and fetal presentation (p < 0.0001) table 3. Also, the high proportion of multiparous women (89.8%) and prior cesarean deliveries (55.9%) logically correlates with the predominance of Group 5 cases. Moreover, obstetric variables such as breech presentation and multiple gestations were accurately classified into Groups 6–9, reinforcing the internal consistency of the RTGCS within our dataset. These findings align with those of previous studies, suggesting that maternal profile plays a critical role in group distribution. This trend is echoed in the study conducted at Benha University Hospital, where Group 5 contributed to 36% of CSs, also predominated by women with parity ≥2 (Jadoon et al., 2020). Similarly, the Al-Azhar University Hospital study in Damietta showed that Group 5 accounted for 56.7% of CS cases, primarily in women aged 30–40 years and with multiple previous births ^{[16, 17, 18]}.

Internationally, an Italian study analyzing Robson groups 1 to 4 showed that in nulliparous women (Groups 1 and 2A), the odds of CS increased significantly from age 30 and peaked at ≥40 years, while in multiparous women (Groups 3 and 4A), the risk of CS rose notably in women aged ≥40 years ^[22].

These comparisons emphasize that maternal age and parity play a substantial role in shaping CS distribution across Robson groups. The persistent dominance of Group 5 underlines the importance of promoting VBAC and re-evaluating indications for repeat CS where clinically appropriate (ACOG, 2019). ^[21]

The relationship between Robson groups and clinical data in our study further emphasizes the value of RTGCS in auditing obstetric practices (table 4). For example, Group 8 included all multiple gestations (4.8% of total), and Groups 6 and 7 captured all breech presentations according to parity. Group 9, representing abnormal lie, had a small but

precise inclusion. Groups 1 to 4 (women with no previous CS) were primarily associated with labor complications like fetal distress and failure to progress, indicating that improved intrapartum care and labor management may help reduce CS rates in these categories. This detailed mapping between clinical indications and Robson groups provides actionable insights for targeted interventions