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Year : 2022  |  Volume : 66  |  Issue : 4  |  Page : 434-438  

Analysis of cesarean section rates and its indications using robson's classification at a tertiary care hospital, Manipur

1 Department of Community Medicine, Regional Institute of Medical Sciences, Imphal, Manipur, India
2 Senior Resident, Department of Community Medicine, Regional Institute of Medical Sciences, Imphal, Manipur, India
3 HOD, Department of Community Medicine, Regional Institute of Medical Sciences, Imphal, Manipur, India
4 Post Graduate Trainee, Department of Community Medicine, Regional Institute of Medical Sciences, Imphal, Manipur, India
5 HOD, Department of Obstetrics and Gynecology, Regional Institute of Medical Sciences, Imphal, Manipur, India

Date of Submission14-Oct-2021
Date of Decision06-Nov-2022
Date of Acceptance15-Nov-2022
Date of Web Publication31-Dec-2022

Correspondence Address:
Brogen Singh Akoijam
Department of Community Medicine and Obstetrics and Gynecology, Regional Institute of Medical Sciences, Imphal, Manipur
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijph.ijph_1928_21

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Context: The World Health Organization proposed the Robson's classification system as a global standard for assessing and comparing cesarean section (CS) rates within health-care facilities over time and between facilities. Aims: This study aims to assess the frequency and indications of CS and to identify the groups within the obstetric population contributing to CS using Robson's classification. Settings and Design: A retrospective chart review was conducted in a Tertiary Care Teaching Hospital in Imphal, Manipur. Methods: All women who delivered between January and December 2019 were classified using the Robson's Ten Group Classification System. The overall CS rate and the CS rate in each Robson's group were calculated. The indications for CS were also recorded. Statistical Analysis Used: Descriptive statistics, such as frequency, percentage, mean, and standard deviation, was used. Results: A total of 10,282 births were reported. The overall CS rate was 35.2%. Group 3 (multiparous women without previous CS in spontaneous labor) (27.6%) and Group 1 (nulliparous women in spontaneous labor) (23.7%) contributed to most of the obstetric populations. The majority of CS belonged to the women in Group 5 (multiparous women with previous lower segment CS) (11%), followed by Group 2 (nulliparous women with labor induced or prelabor CS) (8.6%) and Group 4 (multiparous women without previous CS were induced or taken for prelabor CS) (5.5%). Conclusions: The study revealed that Groups 5, 2, and 4 contributed to the high CS rate. Efforts to reduce the overall CS rate should be directed at increasing vaginal births after CS, performing effective pelvic examinations, and encouraging obstetricians to perform versions when indicated.

Keywords: Cesarean section, pregnancy, Robson's Ten Group classification system

How to cite this article:
Janani L, Christina S, Akoijam BS, Nameirakpam D, Laiphrakpam RS. Analysis of cesarean section rates and its indications using robson's classification at a tertiary care hospital, Manipur. Indian J Public Health 2022;66:434-8

How to cite this URL:
Janani L, Christina S, Akoijam BS, Nameirakpam D, Laiphrakpam RS. Analysis of cesarean section rates and its indications using robson's classification at a tertiary care hospital, Manipur. Indian J Public Health [serial online] 2022 [cited 2023 Feb 1];66:434-8. Available from:

   Introduction Top

Cesarean section (CS) is an important surgical procedure that can save the life of a woman and her baby when medically indicated. Nonetheless, it is associated with the risk of blood transfusions, hysterectomy, and death as compared to vaginal delivery. CS increases the chances of uterine rupture, placenta previa, ectopic pregnancy, stillbirth, preterm birth, and placenta accreta in future pregnancies. An association between CS use and a greater incidence of late childhood obesity and asthma is frequently reported.[1] Over the past decades, the world has witnessed a rise in CS rates which are not only in high-risk patients but also in low-risk patients. A World Health Organization (WHO) global survey showed that increased CS rates are associated with increased fetal mortality rates, with a higher number of infants admitted to intensive care units compared with infants born by vaginal delivery.[2] In India, the rate of CS delivery has increased from 8.5% to 17.2% between 2005–2006 and 2015–2016. As per the National Family Health Survey (NFHS-V), the total live births delivered by CS in Manipur was 25.6% which was higher than NFHS-IV (21.1%).[3]

The rise in CS rate is due to, rise in the number of women with previous CS, increased use of electronic fetal monitoring, an increasing number of elderly primigravida, increased labor induction, increased CS on maternal request, and pregnancies following infertility treatment.[4] In 1985, the WHO issued a statement in a meeting of reproductive health experts held at Fortaleza, Brazil, that “there is no justification for cesarean delivery rate higher than 10%–15%” – the rate that is associated with the lowest rates of maternal and infant mortality.[5]

Existing CS indications are poorly defined, often multiple, and inconsistently applied. There is often an overlap between indications.[6] It is crucial to have a standard classification system for the classification of CS delivery indications that is accepted at national and international levels. In 2015, the WHO proposed the Robson's Ten-Group Classification System (RTGCS) as a global standard for assessing, monitoring, and comparing CS rates within health-care facilities. This system classifies women into one of ten categories according to parity, the onset of labor, gestational age, fetal lie, and the number of fetuses. This classification helps institution-specific monitoring and offers a comparison between institutions and at different time points within the same institution. Such an analysis gives health-care providers evidence-based information so they can know where to target their efforts for maximum effect in reducing the rate of CS.[7]

There are very few studies in India conducted using this classification. It is high time to inculcate RTGCS as a routine for recording and reporting CS rates in health-care facilities. This will enable us to identify the major contributor to the CS rate and plan effective strategies to reduce the number of CS wherever possible. Hence, this study was conducted to assess the frequency and indications of CS and identify the groups within the obstetric population contributing to CS using RTGCS.

   Materials and Methods Top

A retrospective chart review was conducted in a Tertiary Care Teaching Hospital in Imphal, Manipur. Ethical clearance for the present study was obtained from the Research Ethics Board of the institute.

All women who were delivered under obstetrics and gynecology department from January to December 2019 were included in the study. A total of 10,282 women delivered, of which 10,223 were classified according to RTGCS [Table 1].[7]
Table 1: Robson Ten group classification system

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Core variables (parity, onset of labor, gestational age, fetal lie, history of previous CS, and a number of fetuses) were abstracted by two researchers from available records in the hospital using a structured case pro forma. After checking for completeness and consistency, the data collected were analyzed according to RTGCS [Table 1] using SPSS 26.0 (IBM Corp. Chicogo, U.S). Descriptive statistics such as frequency, percentage, mean, and standard deviation was used.

   Results Top

During the study, a total of 10,282 women delivered, of which the mean age of the women was found to be 27.1 ± 5.7 years. Fifty-nine women were excluded from Robson's classification due to missing data pertaining to one of the core variables. Multiparous women contributed to 56.4% of overall deliveries. About 12% of pregnant women had a previous history of at least one CS. Overall, the CS rate was 35.2%, of which the maximum (82.1%) of them underwent the emergency procedure. Nearly one-fourth (23.9%) of women had undergone CS before the onset of labor pain. Preterm and term deliveries had contributed 7.8% and 90.6% of total deliveries, respectively [Table 2].
Table 2: Demographic characteristics of all deliveries (n=10,282)

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Classification of the women according to RTGCS revealed that most women belonged to Robson Group 5 (11%), which consists of multiparous women with at least one previous uterine scar with single cephalic pregnancy at term, followed by Group 2 (8.6%) and Group 4 (5.5%). They were the term nulliparous (Group 2) and multiparous (Group 4) women with a singleton pregnancy who either had labor induced or were delivered by CS before labor. Group 1 also contributed significantly (3.01%) to the CS rate. This group accounted for approximately one-quarter of the total obstetric population (23.7%) [Table 3].
Table 3: Cesarean section rates among women groups according to Robson Ten Group Classification System (n=10,223)

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The largest group in the obstetric population is Robson Group 3 (27.6%) which is comprised term multiparous women without a previous uterine scar with singleton pregnancy in spontaneous labor. This group had a low CS rate (1.8%).

Robson Group 9 (all women with a single pregnancy with a transverse or oblique lie, including women with previous uterine scars) had a very high rate of CS (94.2%) next to Group 5. However, this group made a relatively small contribution to the overall CS rate (0.5%) [Table 3].

As shown in [Figure 1], the most common indications of CSs were prior history of CS delivery (36.7%; 1331), followed by cephalopelvic disproportion (CPD) (19.6%; 710), amniotic fluid disorders (13.6%; 491), premature rupture of membrane (PROM) (11.1%; 403), and maternal medical indications such as thyroid disorders, heart diseases, and gestational diabetes mellitus (10%; 364). Group 5 was further analyzed according to the indications of CS. The history of previous cesarean deliveries itself was the indication in 1056 (89.1%) women, followed by CPD 124 (10.4%), and maternal medical disorders 112 (9.5%).
Figure 1: Indications of CS (n = 3622). CS: Cesarean section, CPD: Cephalopelvic disproportion.

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In Group 2, CPD (190; 12.3%), followed by amniotic fluid disorders (172; 11.2%) and PROM (166; 10.8%) were the most common indications of CS.

   Discussion Top

A total of 10,282 pregnant women were delivered from January to December 2019. The CS rate of 35.2% in our study was comparable to the rate in Puducherry (32.6%), Bhutan (34.2%), and Egypt (38.5%).[8],[9],[10] The high CS rate suggests the hospital CS rate and not the population CS rate, but much higher than the rate (10%–15%) proposed by the WHO in 1985. It is also higher when compared to other studies conducted in Delhi (23.5%), Sri Lanka (25.1%), and Tamil Nadu (27.2%).[11],[12],[13] However, some studies have reported slightly higher CS rates.[4],[14],[15],[16],[17],[18] The high CS rate in our finding could be explained by the high referral of complicated pregnancies to the hospital. Differences may be the result of differences in the obstetric population, sample size, and physician's practice style.

In the present study, the RTGCS was used to identify the groups of women that accounted for the rise in CS. Among the various groups, Group 5 contributed the maximum to the overall CS rate (Absolute contribution – 11%; Group CS rate – 94.9%) and was the third-largest group in this study (11.5% of the women). This was consistent with various studies conducted in India and other parts of the world.[4],[9],[10],[11],[13],[16],[17],[19] The most common indication was a history of one or more previous CS deliveries (89.1%). According to Robson's guideline rates of 50%–60% with good maternal and perinatal outcomes are considered appropriate. The higher rate in this study could possibly be due to a large Group 5.1 (women with one previous CS; 10.3%). A decline in the number of women who attempt vaginal birth after CS (VBAC) is due to fear of complications like a uterine rupture. Women's misinformation could be another reason. Moreover, it is a common practice to recommend an elective repeat CS to women with one or more CS. In the current study, out of 1184 women in Group 5, only 5.1% had successful VBAC. In an appropriately selected patient, the vaginal delivery success rate with VBAC is at 72%–75% with low maternal and perinatal morbidity according to the Royal College of Obstetrician and Gynecologists.[20] Indian studies indicated that 60%–80% of women can achieve a safe vaginal delivery after a previous CS.[21],[22] Furthermore, medicolegal reasons are an added factor of CS in Post-CS. The high rate may indicate that in previous years, CS rates in Groups 1 and 2 have been high. The Group 5 contributed at most to the overall CS rate, so any action aimed at lowering the CS rate for this group would reduce the overall CS rate. One of the best approaches to reduce the size of this group is decreasing the primary CS.

The second-largest contributor to the overall CS rate (Absolute contribution – 8.6%) was nulliparous women with induction of labor or elective CS (Group 2). This rate is lesser than the rates reported in other studies.[11],[23],[24] In Group 2, out of 1539 women, 780 (50.7%) were induced and 759 (49.3%) were taken for CS before labor. In the induced Group, 141 (18.1%) were delivered by CS. This finding is similar to the study conducted by De et al.[11] and Nalam and Emmanuel[13] In a meta-analysis of 31 trials, it was seen that induction of labor was associated with a reduction in the risk of CS as compared with expectant management.[25] Major indications for CS in Group 2 were CPD, amniotic fluid disorders, PROM, and failed induction.

In Group 4, CS rate was 5.5% (Group CS size – 53.3%). As per Robson, the CS rate in this group should be below 15%. Group 4a (50.6%) and 4b (49.4%) were more or less equal in size. The success rate of induction among Group 4a women was 88.9%. Therefore, absolute indications for the induction of labor must be carefully made to reduce the CS rate in this group. The high CS rate in this group could be due to poor data collection (inclusion of women with previous CS in this group) or scheduling prelabor CS for nonmedical indications.[26] A high rate may reflect a high maternal request for CS, which may be influenced by a previous traumatic or prolonged labor.[7] Any plan for reducing the rate of cesarean delivery in this group should include an update of the guidelines for labor induction and proper monitoring of women during the induction of labor, with a clear time frame as to when induction is considered to have failed.[10]

Interventions like CS decision with the signature of three obstetricians, re-evaluating the CS decision in the next 24 h, and strictly obeying the failed induction algorithm will significantly decrease the CS rate in Groups 2 and 4.[19] In 2011, the WHO stated that induction of labor should be performed only when there is a clear medical indication for it and the expected benefits outweigh its potential harms.[27] A failed induction can be repeated; it does not necessitate CS if there is no emergency indication.[28]

In this study, term multiparous women without a previous uterine scar, with a single cephalic pregnancy in spontaneous labor (Group 3), included the majority of the obstetric population (27.6). This group contributed to 1.8% of the CS rate. CPD, amniotic fluid disorders, maternal medical complications, and fetal distress were the most common indications of CS in this group also.

The CS rate among the Group 1 was 3.01% (Group CS size – 12.7%). According to Robson, a rate for Group 1 <10% is desirable. CPD, amniotic fluid disorders, maternal medical conditions, fetal distress, and premature rupture of membranes were the most common reasons where a substantial number of nulliparous undergoing primary CS. A reduction in the rate of CS delivery among nulliparous women will reduce the relative size of Group 5.

CS rates in women in groups 1-4 can be reduced with effective pelvic examination. Measuring liquor volume on ultrasound is a subjective assessment and must be taken into account along with other obstetric and medical factors before deciding for CS.[12]

Groups 6 and 7 contributed 2.1% to the overall CS rate. Dhodapkar et al.,[8] Bha et al.,[14] and Samba and Mumuni[15] have also noted high CS rates in breech presentation. This group CS size can be reduced by the timely diagnosis of breech presentation and an offering external cephalic version (ECV) to all suitable women.

More than one-fourth (29.3%) of the women with pre-term deliveries in Group 10 had to undergo prelabor CS particularly due to the previous history of CS, maternal hypertensive disorder, and PROM. The size of Group 10 in our study was 7%. Being a tertiary care hospital, capable of managing life-threatening maternal and newborn conditions, many pregnant women are transferred when a pre-term delivery is considered. There is a conflict among obstetricians regarding the decision to choose between induction of labor or CS in moderate pre-eclampsia, pre-term PROM.[9]

The relative contribution of Groups 1, 2, and 5 to the overall CS rate was 64%. These groups usually contribute to two-thirds of all CS performed in most hospitals. These groups should be the focus of attention if the hospital is trying to lower the overall CS rate.

The size of Groups 1 and 2 in our study was 38.7%. Multiparous women with single cephalic full-term pregnancies (Groups 3 and 4) represented 38% of all the deliveries and had contributed 7.3% to the overall CS rate. This shows that the hospital was catering to a high proportion of women with more than one child rather than only one child.

According to RTGCS, Group 9 is a good marker to assess data quality because it is very consistent in size, between 0.2% and 0.6%, with a CS rate of nearly 100%. In our study, Group 9 had a relative size of 0.5% with a 94.2% CS rate. We can therefore conclude that our data is of acceptable quality.

This study is the first of its kind to use RTGCS to analyze the CS rate in a tertiary care teaching hospital in Manipur with a larger number of secondary data. The study also demonstrated the ease and feasibility of implementing Robson's classification in a hospital setting. The major limitation of the study is its retrospective nature. A prospective study will be more informative. Another limitation is the possibility of recording errors in medical records.

   Conclusions Top

As per Robson's classification, Group 5 (women with previous CS) was identified as the main contributor to the overall CS, followed by Group 2 (nullipara with induced labor/prelabor CS) and Group 4 (multipara with induced labor/prelabor CS). It is important that efforts to reduce the overall CS rate should focus on reducing the primary CS rate. In our study, we found that the major contributors to primary CS were CPD, amniotic fluid disorders with or without fetal distress, PROM, and maternal medical disorders. Skilled pelvic examinations, encouraging VBAC, and continuing ECV will help in reducing the CS rate. From our study, we are suggesting that the incorporation of RTGCS as a part of quality improvement will reduce unnecessary CS rates in tertiary care hospitals. RTGCS can be applied at an institutional level to monitor the trend of CS rates. It helps to plan effective strategies targeted at specific subgroups of women to rationalize the CS deliveries and to improve feto-maternal outcomes.

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Conflicts of interest

There are no conflicts of interest.

   References Top

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  [Table 1], [Table 2], [Table 3]


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