A Robson classification-based audit of cesarean section rates and public health implications in a tertiary care center in India.

INTRODUCTION

The rising global cesarean section rate, surpassing 21% globally and reaching up to 50% in some Indian settings, represents a growing public health challenge. In the absence of clear obstetric indications, unnecessary cesarean section contributes to increased maternal morbidity, neonatal complications, and avoidable healthcare expenditures. India's healthcare system has witnessed a steady escalation in cesarean section rates, necessitating urgent audit mechanisms to guide corrective strategies. The World Health Organization (WHO) Robson Ten-Group Classification System offers a standardized framework to audit and address cesarean section overuse by stratifying women based on key obstetric parameters.

OBJECTIVES

This study aimed to assess cesarean section rates and their clinical and public health implications in a tertiary government hospital in Delhi.

METHODS

A retrospective audit of 2637 deliveries conducted between July 2024 and September 2025 was performed. Data were extracted from hospital records and classified using the WHO Robson system. Primary outcomes included overall and group-wise cesarean section rates; secondary outcomes included referral status, clinical indications for cesarean section, and maternal-neonatal outcomes by delivery mode. Only complete records were included; data quality checks were undertaken to minimize entry errors and missing fields.

RESULTS

The overall cesarean section rate was 36.7%. Group 5 (previous cesarean section) contributed the highest proportion (84.5% group-specific cesarean section rate), followed by Group 2 (nulliparous, induced or pre-labor cesarean section) and Group 1 (nulliparous, spontaneous labor). Cesarean section rates were significantly higher among referred women (51.3%) versus non-referred women (30.3%). The most common indication for cesarean section was previous cesarean section without trial of labor (28.9%). Cesarean deliveries were associated with higher rates of postpartum hemorrhage, wound infection, were neonatal intensive care admission, and low Apgar scores.

CONCLUSION

This study highlights a concerning overuse of cesarean sections, particularly among low-risk groups and referred patients, with Group 5 (previous cesarean section) contributing the highest proportion. The findings underscore the utility of the WHO Robson classification in identifying priority areas for intervention. To address the rising cesarean section trend in public health settings, targeted efforts are needed to strengthen labor management in peripheral centers, encourage safe vaginal birth after cesarean, and promote adherence to evidence-based obstetric practices.