CESAREAN SECTION RATES AND THEIR INDICATIONS USING THE ROBSON TEN-GROUP CLASSIFICATION SYSTEM: A NARRATIVE REVIEW OF EVIDENCE FROM PAKISTANI TERTIARY-CARE HOSPITALS

Abstract

Background: The rising global and national rate of cesarean section (CS) is a pressing maternal and public health concern. The World Health Organization (WHO)-endorsed Robson Ten-Group Classification System (RTGCS) offers a standardized method for auditing, monitoring, and comparing CS rates according to clinically relevant obstetric characteristics, enabling institutions and health systems to identify the specific patient groups driving their overall CS rate.To synthesize published evidence from Pakistani tertiary-care hospitals that have applied the RTGCS, in order to characterize overall CS rates, the relative contribution of individual Robson groups, and the leading clinical indications for cesarean delivery. Methods: A narrative review of the literature was conducted using PubMed, Google Scholar, and institutional repositories for studies published between 2015 and 2026 that reported RTGCS-based audits from Pakistani tertiary-care obstetric units. Data on study design, sample size, overall CS rate, group-specific contributions, and indications were extracted and synthesized descriptively; no formal meta-analysis or systematic quality appraisal was performed. Results: Four Pakistani tertiary-care audits meeting the review criteria reported overall institutional CS rates ranging from 39.9% to 54.2%, several-fold above the WHO reference range of 10-15% and considerably above Pakistan's national rate of 19.6% (Pakistan Demographic and Health Survey, 2017-18). Across the three hospitals reporting group-specific contributions, Robson Group 5 (women with a previous cesarean section) was consistently the largest single contributor, accounting for 34.3-51.9% of the overall CS rate, followed variably by Group 10 (preterm singleton cephalic pregnancies, 14.4-28.5%) and Group 2 (nulliparous women induced or delivered by CS before labor, 12.7-18.5%). In the most detailed audit (Holy Family Hospital, Karachi), the leading clinical indications for emergency CS were previous cesarean section (32.3%), non-progress of labor (21.15%), and cephalopelvic disproportion (16.92%). Conclusion: Evidence from Pakistani tertiary-care hospitals consistently identifies previous cesarean delivery, preterm singleton pregnancies, and nulliparous induced labor as the principal contributors to elevated institutional CS rates. Promotion of vaginal birth after cesarean (VBAC) where appropriate, judicious use of induction in nulliparous women, and structured management of preterm pregnancy are plausible targets for reducing potentially avoidable CS. Routine, standardized RTGCS-based auditing is recommended across Pakistani obstetric units to enable meaningful benchmarking and to guide targeted quality-improvement interventions.

Keywords: Cesarean section; Robson Ten-Group Classification System; obstetric audit; previous cesarean section; tertiary care hospital; Pakistan; vaginal birth after cesarean