Study aim: Cesarean section (CS) rates have been on the rise globally, including in Saudi Arabia. This study examines the use of Robson’s classification system to analyze CS rates, indications, and opportunities for improvement in maternity care.

Methods: A retrospective analysis was conducted on 784 CS cases in a tertiary hospital in Jeddah, Saudi Arabia, using Robson’s classification. The study categorizes women based on obstetric characteristics such as parity, gestational age, fetal presentation, and previous CS.

Results: The primary indication for cesarean section in our study population was a history of previous cesarean section (63.65%). According to Robson’s classification, Group 5, consisting of multiparous women with at least one previous uterine scar and a single cephalic pregnancy beyond 37 weeks, contributed the most to the overall CS rate (54%). Groups 9 (single pregnancy with transverse or oblique lie, including women with previous scars) and 7 (multiparous women with a single breech, including women with previous scars) were the second and third most common groups (23.10%) and (14.90%) of the cases, respectively.

Conclusion: Robson’s classification provides valuable insights into CS indications. Efforts should focus on reducing the CS rate, particularly among nulliparous women. Regular monitoring and evidence-based interventions are recommended to enhance safe childbirth practices in Saudi Arabia.

• Cesarean section

• Robson’s classification

• Indication of Cesarean sectio

AlBasri S, AlHibshi D, Althakafi K, Alolyan S (2023) Assessing Cesarean Section Rates and Indications in Saudi Arabia: A Robson Classification Analysis for Maternity Care Improvement. Med J Obstet Gynecol 11(3):1178.

Cesarean section (CS) rates have seen a significant surge globally over the past few decades, sparking critical discussions within the healthcare community. This escalating trend, particularly pronounced in high-income countries, has raised questions about the appropriateness and necessity of CS procedures. While the World Health Organization (WHO) once recommended regional CS rates of 10% to 15%, the validity of this guideline has been challenged as CS rates continue to climb [1,2]. Saudi Arabia, in particular, stands as an emblematic case with a consistently high CS rate of approximately 10%, well above the WHO’s threshold [3]. This nation confronts pressing questions regarding maternal healthcare practices and the wellbeing of both mothers and infants, given the multifaceted factors contributing to this upward trajectory, such as maternal age, primiparity, and healthcare provider preferences [4,5].

Robson’s classification system offers a valuable framework for categorizing CS data based on critical obstetric characteristics, including parity, gestational age, fetal presentation, and previous CS [6]. By examining the CS rates and indications through the lens of Robson’s classification, this study endeavors to furnish valuable insights that can inform strategies to optimize maternity care in Saudi Arabia.

Cesarean section trends worldwide have experienced a consistent upward trajectory, sparking debates on the appropriateness and necessity of the procedure. Historically, the WHO recommended regional CS rates of 10% to 15% [1], but the validity of this guideline has been questioned as CS rates continue to rise, particularly in high-income countries [2]. Saudi Arabia, emblematic of this global trend, grapples with questions surrounding maternal healthcare practices and the well-being of mothers and infants [4]. Several factors contribute to this phenomenon, including advanced maternal age, primiparity, and physician preferences [5,6].

A key development in understanding CS rates and indications has been the implementation of Robson’s classification system. This system provides a valuable framework for categorizing CS data based on obstetric characteristics such as parity, gestational age, fetal presentation, and previous CS [7]. Robson’s system has been recognized by the WHO as a global standard for measuring and comparing CS rates, offering benefits such as mutual exclusivity, comprehensiveness, and prospective applicability [8].

Saudi Arabia exhibits unique characteristics in terms of maternal health. The nation boasts generally good maternal health, with the majority of women receiving antenatal, prenatal, and postnatal care [9]. The maternal mortality rate per 10,000 live births was 1.4 in 2009 [10]. Approximately 90% of births occur in hospitals [11]. Despite these positive indicators, the CS rate remains persistently high [3].

Studies have shown significant variations in CS rates both within Saudi Arabia and globally. In Saudi Arabia, these rates vary significantly among different cities, ranging from 16.9% to 34.1% [12]. Similarly, international studies have revealed variations across different regions and healthcare facilities [13]. This variability underscores the need for a comprehensive classification system such as Robson’s to dissect CS rates and indications, as well as to identify opportunities for improvement.

A systematic review by Betrán et al. synthesized user experiences with Robson’s classification in over 33 million women from 31 countries [14]. Users praised the system for its simplicity, robustness, dependability, and adaptability. However, challenges include missing data, misclassification, and a lack of consensus on classification characteristics. Several proposed improvements, especially in the group covering women with previous CS, emphasize the system’s capacity for refinement [14].

The utility of Robson’s classification system has been demonstrated in various countries. A study conducted by Parveen et al. in Pakistan used Robson’s classification to analyze trends in CS rates and found that groups 10 and 5 contributed the most to total deliveries [15]. These experiences highlight the global applicability of Robson’s classification system.

Study aim

This study employed a retrospective analytical comparative design to assess CS rates and indications in King Abdulaziz University Hospital in Jeddah, Saudi Arabia. The retrospective approach allowed us to analyze a large dataset of CS cases from a tertiary hospital in Jeddah, Saudi Arabia.

Study Duration

Data collection for this study spanned February 15, 2022, to April 30, 2022. This timeframe was chosen to ensure an adequate sample size while capturing a representative snapshot of CS cases within the hospital.

Study Setting

The study was conducted at a single healthcare center in Jeddah, Saudi Arabia. The choice of this specific healthcare center was based on its accessibility and the availability of comprehensive medical records.

Study Population

The study focused on women who underwent cesarean section procedures at the selected healthcare center during the study period. Inclusion criteria required that the medical records of these women contained complete follow-up data.

Selection Criteria

Inclusion criteria

• Women who underwent CS procedures at the healthcare center.

• Medical records with complete follow-up data.

Exclusion criteria

• Women with incomplete data records.

• Women with chronic medical conditions that could potentially affect pregnancy or mode of delivery

Data Collection

Data were collected from electronic health records (EHRs) and paper-based medical records using a structured data collection form. The form included the following variables: patient demographics (age, sex), maternal medical history (including any chronic conditions), date of admission, management plan (including indications for CS), type of CS (primary or repeat), date of CS, and follow-up data.

Ethical considerations

The study was conducted in compliance with ethical principles and was granted approval by the Institutional Review Board (IRB) of the King Abdulaziz University. The study only utilized deidentified data, ensuring the privacy and confidentiality of patient information. No personal identifying information, such as names, contact information, or addresses, was included in the dataset.

Statistical Analysis

Data were analyzed using appropriate statistical software (e.g., SPSS, R). Descriptive statistics, including frequencies, percentages, means, and standard deviations, were calculated to summarize the demographic and clinical characteristics of the study population. Robson’s classification system was employed to categorize the data into mutually exclusive groups based on obstetric characteristics. These groups were subsequently analyzed to determine CS rates and indications.

Demographic Characteristics

A total of 784 CS deliveries were included in the analysis.The mean age of the participants was 32.9 years (± 5.4), with the majority falling within the 20 to 35 years age group, comprising 509 individuals (64.90%). Of the study population, 681 (86.70%) were multigravida, while 103 (13.13%) were primigravida (Table 1).

Table 1: Characteristic of studied women (n=784)

Gestational Age and Fetal

Presentation Gestational age analysis revealed that 353 cases (45.03%) occurred in term pregnancies (37 to 42 weeks). Singleton pregnancies constituted the majority, with 737 cases (94.00%), while twins and triplets accounted for 44 (5.60%) and 3 (0.40%) cases, respectively. Cephalic fetal presentation was predominant, with 603 cases (76.91%), followed by breech presentation in 141 cases (17.98%). Regarding the onset of labor, 229 cases (29.20%) experienced spontaneous labor, while 121 cases (15.40%) were induced (Table 2).

Table 2: Obstetrics characteristics of studied women (n=784).

Indications for Cesarean Section

The primary indication for cesarean section in our study population was a history of previous cesarean section, with 499 cases (63.65%). Other significant indications included multiple gestations, accounting for 36.99% of cases. Fetal distress, while a substantial factor, was the primary indication in only specific groups.

Robson’s Classification Groups

Robson’s classification system was applied to categorize the data into mutually exclusive groups. Group 5, consisting of multiparous women with at least one previous uterine scar and a single cephalic pregnancy beyond 37 weeks, contributed the most to the overall CS rate, with 423 cases (54%). Groups 9 (single pregnancy with transverse or oblique lie, including women with previous scars) and 7 (multiparous women with a single breech, including women with previous scars) were the second and third most common groups, with 181 (23.10%) and 117 (14.90%) cases, respectively. Group 1, encompassing nulliparous women with a single cephalic pregnancy beyond 37 weeks in spontaneous labor, had the least contribution (Table 3) (Figure 1).

Table 3: Study Participants According to the Robson Classification System (n=784)

Figure 1: Indications of CS among ten groups of Robson classification system.

Fetal Presentation in Singleton

Pregnancies Within the subset of singleton pregnancies (737 cases), cephalic presentation remained predominant at 80.2%. Notably, breech presentation was more frequent among twins, accounting for 39.1% of cases, compared to singletons and triplets (Table 4) (Figure 2).

Table 4: Fetal Lies According to Number of Neonates (n=784)

Figure 2: Fetal lies in association with onset of labor (n=784).

Interpretation of Findings

Our study examined CS rates and indications in Saudi Arabia using Robson’s classification system, shedding light on the distribution of CS among various obstetric groups. The results reveal several significant trends that warrant careful consideration.

Robson’s Classification and Group Contributions

Robson’s classification system provided a comprehensive framework for categorizing CS data based on obstetric characteristics. Group 5, comprising multiparous women with at least one previous uterine scar and a single cephalic pregnancy beyond 37 weeks, emerged as the primary contributor to the overall CS rate. This finding is consistent with the literature, emphasizing the importance of addressing CS rates among women with a previous CS history [15].

Indications for Cesarean Section

Our study identified a history of previous CS as the primary indication for CS, accounting for a substantial proportion of cases. This echoes the global trend where a prior CS is often a crucial factor in the decision for CS delivery [16]. These findings underscore the necessity of exploring strategies to reduce unnecessary CS among women with previous uterine scars while ensuring maternal and neonatal safety.

Comparative Analysis and Variation

Our results also contribute to the broader discourse on CS rates by comparing them to international trends. While the global rise in CS rates has raised concerns, our study confirms that Saudi Arabia is not an exception to this phenomenon [3]. The variation in CS rates among different cities within Saudi Arabia aligns with similar disparities observed in other countries [12]. Further investigations are warranted to explore regional differences in CS rates and potential underlying factors.

Clinical Implications

The clinical implications of our findings are substantial. While CS can be life-saving in certain situations, their overuse can lead to increased healthcare costs, longer recovery times, and potential complications for both mothers and infants [17]. Our study highlights the importance of evidence-based decision-making in obstetric care to balance the benefits and risks of cesarean delivery. Targeted interventions and improved communication between healthcare providers and expectant mothers may help reduce the reliance on CS, particularly among women with a history of previous CS.

We acknowledge several limitations in our study. First, the data were collected from a single healthcare center in Jeddah, which may not fully represent the national context. Second, retrospective data collection is subject to inherent limitations, such as missing or incomplete records. Additionally, the study did not explore the specific reasons for the high CS rates in Saudi Arabia, which is an avenue for future research.

Future Directions

Future research should delve into the underlying factors contributing to the high CS rates in Saudi Arabia, considering variables such as maternal age, education, socioeconomic status, and healthcare provider preferences. Comparative studies across different regions of Saudi Arabia can uncover regionspecific patterns and inform targeted interventions. Moreover, investigating the quality of antenatal and intrapartum care can shed light on potential areas for improvement in maternity services.

In this study, utilizing Robson’s classification system, we identified multiparous women with a prior CS history (Group 5) as the primary contributors to the overall CS rate in Saudi Arabia. The predominant indication for CS was a history of previous CS. To address this, we recommend the implementation of evidencebased guidelines, an emphasis on vaginal birth after CS when appropriate, and improved communication between healthcare providers and expectant mothers.

Future research should explore factors contributing to high CS rates, considering variables such as maternal age, education, socioeconomic status, and provider preferences. Additionally, comparative studies across different regions within Saudi Arabia can provide valuable insights. In conclusion, our study informs efforts toward a more evidence-based and patient-centered maternity care approach in Saudi Arabia, with the overarching goal of ensuring the well-being of both mothers and newborns.

1. World Health Organization. WHO statement on caesarean section rates. 2015.

2. World Health Organization. Appropriate technology for birth. Lancet. 1985; 2: 436-437.

3. Ye J, Betrán AP, Guerrero Vela M, Souza JP, Zhang J. Searching for the optimal rate of medically necessary cesarean delivery. Birth. 2014; 41: 237-244.

4. Gibbons L, Belizan JM, Lauer JA, Betran AP, Merialdi M, Althabe F. Inequities in the use of cesarean section deliveries in the world. Am J Obstetr Gynecol. 2012; 206: 331-e1.

5. Liu S, Liston RM, Joseph KS, Heaman M, Sauve R, Kramer MS, et al. Maternal mortality and severe morbidity associated with low-risk planned cesarean delivery versus planned vaginal delivery at term. CMAJ. 2007; 176: 455-460.

6. Souza JP, Gülmezoglu A, Lumbiganon P, Laopaiboon M, Carroli G, Fawole B, et al. Caesarean section without medical indications is associated with an increased risk of adverse short-term maternal outcomes: the 2004–2008 WHO Global Survey on Maternal and Perinatal Health. BMC Med. 2010; 8: 71.

7. Ba’aqeel HS. Cesarean delivery rates in Saudi Arabia: a ten-year review. Ann Saudi Med. 2009, 29: 179-183.

8. Robson MS. Can we reduce the caesarean section rate? Best Pract Res Clin Obstet Gynaecol. 2001; 15: 179-194.

9. 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: e14566.

10. Vogel JP, Betrán AP, Vindevoghel N, Souza JP, Torloni MR, Zhang J, et al. Use of the Robson classification to assess caesarean section trends in 21 countries: a secondary analysis of two WHO multicountry surveys. Lancet Glob Health. 2015; 3: e260-270.

11. Ministry of Health (MOH) (2010) Health Statistical Year Book. Saudi Arabia: Ministry of Health [Online]. 2022.

12. World Health Organization (WHO) (2006) Health Systems ProfileSaudi Arabia. Eastern Mediterranean Regional Health Systems Observatory- EMRO: World Health Organization. 2022.

13. World Health Organization (WHO) (2014) World health statistics 2014. World Health Organization. 2014.

14. Khresheh R, Homer C, Barclay L. A comparison of labour and birth outcomes in Jordan with WHO guidelines: a descriptive study using a new birth record. Midwifery. 2009; 25: e11-18.

15. Hassan-Bitar S, Wick L. Evoking the guardian angel: childbirth care in a Palestinian hospital. Reproductive Health Matters. 2007; 15: 103- 113.

16. Bragg F, Cromwell DA, Edozien LC, Gurol-Urganci I, Mahmood TA, Templeton A, van der Meulen JH. Variation in rates of cesarean section among English NHS trusts after accounting for maternal and clinical risk: cross-sectional study. Obstetric Anesthesia Digest. 2011; 31: 160-161.

17. Betran AP, Vindevoghel N, Souza JP, Guelmezoglu AM, Torloni MR. A systematic review of the Robson classification for caesarean section: what works, doesn’t work and how to improve it. PloS one. 2014; 9: e97769.

18. Parveen R, Khakwani M, Naz A, Bhatti R. Analysis of Cesarean Sections using Robson’s Ten Group Classification System. Pak J Med Sci. 2021; 37: 567.