Introduction

Cesarean section is the delivery of fetus through abdominal uterine incision after fetal viability, 28 weeks and above. The rising cesarean section is a global concern, and the rate has exceeded 30% in some regions. As per the World Health Organization (WHO) statement in the year 1985, C-section rate higher than 10–15% is not justified for any region.(1) Even after thirty years of the publication of the WHO guidelines in the year 2015, there is no consensus about the optimal CS rate and appropriate interpretation of this indicator remains a topic of debate.(2) More recent efforts to determine the optimal C-section rate also had limitations due to lack of external validity and confounders.(2,3) The most common complications associated with cesarean sections are increased requirements of blood transfusions, retained placenta, postpartum hemorrhage, prolonged hospital stays and increased changes of maternal morbidity and mortality. (4, 5) Rising trends in C-section rates are feared to implicate lower threshold of labour pains maternal requests, labour induction without indications and lesser levels of expertise adopting instrumental deliveries.(6-8)

There are several reasons which explain variations in institutional rates of C-section. These include the inherent differences in patient characteristics, type of institution and available resources. In addition, institutional differences in obstetric practice and pregnancy and labor management protocols can account for this variation. (6) Therefore, population-based C-section rates should not be considered as recommended targets at facility level. Indeed, systems designed to monitor cesarean section rates at facilities should consider these differences. C-section rates should no longer be thought of being too high or too low but rather whether they are appropriate. Thus, C-section should only be conducted based on medical indications, and efforts should be directed towards improving access to all women in need rather than striving to achieve an arbitrary rate.(6,7) Therefore, policymakers, program managers, clinicians, and administrators need a standardized and internationally accepted classification system to monitor and compare C-section rates in a meaningful, reliable, and action-oriented manner. (8) A systematic review of existing C-section classification system conducted in 2011 identified 27 different classification systems of which Robson’s Ten Group Classification System (RTGCS) was found to be the best option.(5-6, 9) Vaginal Birth After Cesarean (VBAC) is a safe alternative to repeat cesarean section for both mother and infant. The major risk of trial of labour is uterine rupture and possible hysterectomy can be reduced by careful patient selection. The Royal college of obstetricians and gynecologists recommends the routine use of VBAC checklist during antenatal counseling as they would ensure informed consent and shared decision making in women undergoing VBAC.(10-12) WHO proposed Robson’s Ten Group Classification System to monitor and compare the rates of C-section between different health institutions in a reliable and action-oriented manner there are many studies that have shown a small reduction in C-section rates following implementation of Robson’s Classification system (Table 1).

The objective of the current study was to audit C-section rate using Robson’s Ten Group Classification System in our tertiary care hospital, and to identify the main contributors of each subgroup to overall C-section rate.

Materials and Methods

Study design

This was a cross-sectional study conducted at out tertiary care center, Karpaga Vinayaga Institute of Medical Sciences and Research Centre (KIMS&RC), Madhuranthagam, Tamil Nadu, India during the period of January 2019 to December 2021. The study was conducted by reviewing the hospital record for analyzing the C-sections performed during the above-mentioned period. The study population include the pregnant women who underwent C-sections in our hospital during the specified period. Study was approved by the Institutional Ethical committee of KIMS&RC after the approval from Scientific Advisory Committee. Sample size was calculated based on the study done by Radhakrishnan T et al on “increasing trend of caesarean rates in India: evidence from NHFS 4” which showed prevalence of caesarean section rates of Tamil Nadu as 34%. (13)

Inclusion Criteria: The study population included all women who gave birth from January 2019 to December 2021.

Exclusion Criteria: Laparotomy done for uterine rupture and deliveries before fetal viability were excluded from the study. Case sheets with missing information were also excluded from the study. Viability is considered after gestational age of 28 weeks or birth weight ≥ 1,000g, if gestational age is unknown. (14, 15)

Information regarding each C-section case was obtained from hospital records of Medical records Department. Using the medical registration number, we accessed all C-sections performed during the study period and all the required details of each case was noted (Age, Parity, Gestational age, fetal presentation, previous deliveries, onset of labour, mode of delivery, birth weight etc.). Distribution of all cesarean deliveries was then categorized as per Robson’s Ten Group Classification System (Table 1).(5,6, 8) The C-section rate in percentage of total delivery and contribution of each group to overall C-section rate was calculated.

The overall caesarean section rate was calculated, and the major contributing factor was also identified. The contribution of each group to caesarean section rate was calculated.

Statistical Analysis: All the data was recorded in an excel sheet and exported for analysis using IBM SPSS, version 16.0 (IBM Corp., USA). The overall C-section rate at the institution was calculated first. We coded all abstracted data and women were categorized into one of the ten Robson groups. For each group, size relative to the entire obstetric population, contribution to the overall C-section rate, and C-section rate within the group were calculated.

Results

The total number of women meeting the inclusion criteria and delivered during the period of study were 401. The overall caesarean section rate during the period of study was 46%. The 401 antenatal mothers who underwent C-section were in the age range of 18 to 38 years and maximum number of women were aged between 21-30 years (68%). The mean age of participants was 25.4 ± 5.2 years.

Of the overall 401 antenatal women who has C-section 46% were primigravida and rest were multigravida (54%). The 401 women who underwent C-section, 93% were term patients and 7% were pre-term. In the study 99% women presented with singleton pregnancies and 1% with multiple pregnancies (Table 2).

The 401 women who underwent C-section were classified in RTGCS, 45% women in Group 5 and it contributed to the maximum number of the total C-section rates. The second highest contributor was Group 1 and Group 2 contributing to 41% of the overall C-section rates. Other groups who underwent C-section, mentioned in the Table 3 and Figure 1.

Figure 1: Shows the no. of antenatal women as per Robson Ten Group Classification System

Out of 401 women analyzed, 298 were emergency LSCS (74%) and 103 were elective LSCS (26%). 95% patients who underwent caesarean section had no complications and 5% of patients had complications like postpartum hemorrhage, blood transfusion and postpartum eclampsia. Totally 407 live babies were delivered including twin births. Maximum number of babies weighed between 2500 gm - 4000 gm (77%) (Table 2). The commonest cause for NICU admission was preterm birth. Other causes were distress at birth and grunting.

Discussion

C-section is a key intervention used to decrease maternal and neonatal morbidity and mortality. (4-6) Despite its proven benefits, complications such as infection, bleeding, anesthetic accidents and even death are associated with C-section. Further, future pregnancies can be complicated by spontaneous preterm birth, uterine rupture, and abnormal placentation.(16,17) The Robson ten group classification system enables institution-specific monitoring and auditing and can be a powerful tool to inform practice across different settings. (6-8) In the present study RTGCS was used for assessing the proportion of each group in the obstetric population, the contribution of C-section in each group to the overall C-section rate. The present study includes 401 mothers who underwent C-section. Among all the groups as per Robson’s TGCS classification, Group 5 contributed to the maximum C-section rates followed by Group 1 and Group 2. This indicates high C-section rate both in primary (groups 1 and 2) and secondary (group 5) C-sections. Our study findings are similar to the study done by Ray A et al and Abubeker FA et al in Ethiopia, the overall C-section rate was 28.9% and 30.8% respectively and Group 10, group 2 and group 5 contributed to maximum to caesarean section rates, 19.1%, 18.3% and 17.1% respectively of the overall C-section rates. (18, 19) Similarly, our study findings are in line with a study done in India where Group 1, Group 2 and Group 5 contributed to 19% and 18% of all deliveries respectively.(20,21)

Cesarean section performed at a rate higher than 10-15% in absence of a clinical justification do not reduce maternal or infant mortality rates. A study performed in China, the maternal morbidity and mortality were lower following VBAC compared with repeated cesareans, but the opposite was seen among Canadian women. Many hospital-based studies adapt Robson’s TGCS for monitoring C-section rates the group 5 is the major contributor to overall C-section rates and found to be the high-risk group by several studies which is also seen in the present study. Mittal et al., reported the C-section trend using Robson classification in north India to assess the trend of C-section rate for 3 years and should a static rate of C-section in each group over the years.(20) In the study conducted by Kacerauskiene at al reaudit of cesarean deliveries should a significant reduction in overall C-section rate from 26.9% in 2012 to 22.7% in 2014(P<0.001).(21) Study by Ray at al has found that women with previous C-section contributes maximum to overall C-section rates followed by term nulliparous who are induced or underwent C-section before labour.(20) In a Canadian study using Robson’s classification most of the obstetric population attributed to group 6(36.6%) and groups 2 and 1 ranked as second and third largest contributors (15.7 and 14.1% respectively).

Several studies across different settings identified Group 5 as the leading contributor to the C-section rate.(13,14,16) In our study, Group 5 was the largest contributor to the overall C-section rate. These findings are suggestive of moderately high C-section rate.(7) which need attention. Though the safety and long-term benefits of vaginal birth after cesarean (VBAC) are well established, 45% of women in Group 5 underwent repeat C-section (Table 3). Thus, there is a need to evaluate the proportion of women who were offered a trial of labor and the success rate of VBAC. This will enable the design and implementation of antenatal counseling strategies and labor management protocols, reducing the number of repeat C-section.

The limitations of this study, as such are the limitations of Robson’s ten group classification system. It does not classify caesarean sections done for specific conditions like major degree placenta previa and those done for maternal request. It also does not classify caesarean sections done for medical, other obstetric complication in the mother and those C-section done for fetal indications E.g: Anhydramnios. As the present study has audited only indications for C-section, it was unable to analyse the total number women in that group and the overall percentage of women in that group requiring C-section versus those who had vaginal delivery which would have added more meaning to the audit.

Conclusion

Robson’s TGCS server as an important tool for auditing C-section and can easily implemented at institutional levels for comparison of C-section rates. As fetal distress is one among the common indication for primary caesarean section and electronic fetal monitoring is the norm, it is important that all obstetricians in the institute are well trained in interpreting of cardiotocography (CTG). The residents must be well trained in procedures like external cephalic version, assisted breech delivery and operative vaginal delivery efforts to reduce overall C-section rate should focus on reducing primary C-section rate and increasing VBAC.

Acknowledgement

The authors would like to acknowledge the medical record section of KIMS&RC for allowing to access the case record files. Authors would like to thank Trustee, Managing Director Dr.R. Annamalai M.S.,M.Ch., for his support in accomplishing this project.

References

1. World Health Organization. Appropriate technology for birth. Lancet 1985;2: 436–437.
2. World Health Organization. Human Reproduction Programme, 10 April 2015. WHO statement on caesarean section rates. Reprod Health Matters 2015; 23:149–150.
3. Betran AP, Ye J, Moller AB, et al. The increasing trend in caesarean section rates: global, regional and national estimates: 1990-2014. PLoS One 2016; 11:e0148343.
4. Ye J, Zhang J, Mikolajczyk R, et al. Association between rates of caesarean section and maternal and neonatal mortality in the 21st century: a worldwide population-based ecological study with longitudinal data. BJOG 2016; 123:745–753.
5. Robson M, Hartigan L, Murphy M. Methods of achieving and maintaining an appropriate caesarean section rate. Best Pract Res Clin Obstet Gynaecol. 2013;27(2):297–308.
6. Robson MS. Classification of caesarean sections. Fetal Matern Med Rev 2001;12(1):23–39.
7. Torloni MR, Betran AP, Souza JP, Widmer M, Allen T, Gulmezoglu M, Merialdi M. Classifications for cesarean section: a systematic review. PLoS One 2011; 6(1):e14566.
8. Dhodapkar SB, Bhairavi S, Daniel M, Chauhan NS, Chauhan RC. Analysis of caesarean sections according to Robson’s ten group classification system at a tertiary care teaching hospital in South India. Int J Reprod Contracept Obstet Gynecol 2017;4(3):745-749.
9. Tanaka K, Mahomed K. The ten-group Robson classification: a single centre approach identifying strategies to optimise caesarean section rates. Obstet Gynecol Int. 2017;2017: 5648938. doi: 10.1155/2017/5648938.
10. Harrison MS, Pasha O, Saleem S, Ali S, Chomba E, Carlo WA, Garces AL, Krebs NF, Hambidge KM, Goudar SS. A prospective study of maternal, fetal and neonatal outcomes in the setting of cesarean section in low-and middle‐income countries. Acta Obstet Gynecol Scand 2017;96(4):410–420.
11. Costa ML, Cecatti JG, Souza JP, Milanez HM, Gulmezoglu MA. Using a Caesarean Section Classification System based on characteristics of the population as a way of monitoring obstetric practice. Reprod Health 2010; 26(7): 13. doi: 10.1186/1742-4755-7-13.
12. Litorp H, Kidanto HL, Nystrom L, Darj E, Essen B. Increasing caesarean section rates among low-risk groups: a panel study classifying deliveries according to Robson at a university hospital in Tanzania. BMC Pregnancy Childbirth 2013;13:107. https://doi.org/10.1186/1471-2393-13-107.
13. Radhakrishnan T, Vasanthakumari KP, Babu PK. Increasing trend of caesarean rates in India: evidence from NFHS-4. Journal of Medical Science and Clinical Research 2017;5(8):26167-26176.
14. Triunfo S, Ferrazzani S, Lanzone A, Scambia G. Identification of obstetric targets for reducing cesarean section rate using the Robson Ten Group Classification in a tertiary level hospital. Eur J Obstet Gynecol Reprod Biol 2015;189:91–95.doi: 10.1016/j.ejogrb.2015.03.030.
15. Sah S, Goel R, Goel JK. Analysis of caesarean section rate according to Robson’s criteria in tertiary care centre. International Journal of Reproduction Contraception Obstetrics Gynecology 2018;7(8):3060–3064.
16. Mittal P, Pandey D, Suri J, Bharti R. Trend prediction for cesarean deliveries based on Robson classification system at a tertiary referral unit of north India. J Obstet Gynecol India. 2020;70(2):111-118.
17. Kacerauskiene J, Bartusevicience E, Railaite DR,et al. Implementation of the Robson classification in clinical practice: Lithuania’s experience. BMC Pregnancy Childbirth. 2017;17:432. https://doi.org/10.1186/s12884-017-1625-9
18. Ray A, Jose S.Analysis of cesarean section according to Robson’s ten group classification system and evaluating the indications within the groups. Int J Reprod Contracept Obstet Gynecol 2017;6(2):447-451.
19. Abubeker FA, Gashawbeza B, Gebre TM, Wondafrash M et al. Analysis of cesarean section rates using Robson ten group classification system in a tertiary teaching hospital, Addis Ababa, Ethiopia: a cross-sectional study. BMC Pregnancy Childbirth 2020;20:767. https://doi.org/10.1186/s12884-020-03474-x.
20. Tura AK, Pijpers O, de Man M, et al. Analysis of caesarean sections using Robson 10-group classification system in a university hospital in eastern Ethiopia: a cross sectional study. BMJ Open 2018;8(4):e020520. doi:10.1136/ bmjopen-2017-020520.
21. Jose J, Arumugam SC, Habeebullah S. An audit of caesarean section rate based on Robson’s ten group classification system. Int J Reprod Contracept Obstet Gynecol 2020;9:2803-2807.