Prevalence and Contributors to Caesarean Section Rates at Maternity and Children’s Hospital, Qassim, Based on Robson Groups

Abstract

Background:

The use of caesarean section (CS) as a mode of delivery has been increasing, eclipsing the World Health Organisation recommendation of 10–15% caesarean deliveries per country. The introduction of Robson’s Ten Group Classification System (TGCS) to standardize the reporting of caesarean deliveries has helped audit and compare CS practices across different countries.

Objective:

This study aimed to determine the overall rate of caesarean deliveries using Robson TGCS, identify the major contributing groups, assess the maternal and clinical predictors of CS, and propose targeted recommendations for reducing unnecessary CSs in a tertiary hospital in Qassim, Saudi Arabia.

Methods:

It is a retrospective study in which 835 women who had delivered through a CS at the Maternal and Children’s Hospital (MCH) in Qassim were included.

Results:

The caesarean deliveries accounted for 46% of the total deliveries conducted within the study period, with Group 5 (multiparous women with at least one previous CS, singleton cephalic, ≥ 37 weeks) being the leading contributor to CS deliveries. The most common indications for CS were previous CS (44.4%), fetal distress (12.8%), and breech presentation (10.5%), whereas maternal obesity (31.6%) and gestational diabetes (5.9%) were the most prevalent comorbidities.

Conclusion:

There is a high repeat CS rate in MCH, Qassim, which highlights the need for targeted interventions, such as promoting vaginal birth after caesarean and auditing CS decisions in low-risk groups.

1. BACKGROUND

The history of caesarean section (CS) dates to the sixteenth and seventeenth centuries. Owing to the high rate of complications, CS was not supported by authorities of that era. In the mid-nineteenth century, it was considered a safer procedure than before, mainly because of improved anaesthetic and surgical techniques and aseptic measures (1).

In the last two decades, the rate of CS has drastically increased. The trend analysis showed that between 1990 and 2014, the global average CS rate increased 12.4% (from 6.7% to 19.1%), with an average annual rate of increase of 4.4% (2). The recommended CS rate by the World Health Organization (WHO) was up to 10–15% for the past 30 years (3), but recently, researchers are providing evidence that is contrary to this rate (4,5) and rates > 10–15% have not shown an improvement in maternal or neonatal mortality (3).

The surge in CS can be attributed to changing delivery practices, with more women opting for elective CS, despite the medical risks (6,7). Women with prior CS are more likely to have repeat CS and potential risks associated with vaginal birth after CS (8)

With the higher CS rate, women are at risk of adherent placenta, multiple blood transfusions, obstetric hysterectomy, complicated surgeries, disseminated intravascular coagulation, multiorgan failure, and mortality (9,10, 11, 12,13, 14, 15,16).

Robson’s Ten Group Classification System (TGCS) uses obstetric parameters to allocate at women at the maternity facility into one of ten groups (17). The groups are structured according to previous obstetric record (parity, previous CS), pregnancy category (foetal presentation and number of foetuses), onset of labour (spontaneous, induced, pre-labour CS) and gestational age at the time of delivery.

The WHO devised Robson’s TGCS for standardised reporting and auditing of CSs (18). The TGCS thus provides a standardised method in accordance with WHO recommendations for comparing CS rates and facilitates the identification of groups that contribute most to CS, thus supporting targeted interventions to optimise obstetric care. This reflects the overall obstetric profile of the institution and makes it possible to evaluate the quality of service, based on which further recommendations can be made for the improvement of services in the institution (19).

The crude birth rate of the Kingdom of Saudi Arabia is 15.27 births per 1000 people (20). The frequency of CSs was 34.6% in 2023, leading to an increase in healthcare cost (21).

Similar to Brazil, India, the Dominican Republic, Egypt, Iran, Australia, and Qatar, where the uptake of CS for medical reasons has massively grown beyond the WHO recommendations (22,23), Saudi Arabia is no exception (24).

Studies in Saudi Arabia consistently identify Robson Group 5 (multiparous women with at least one previous CS, single cephalic, ≥ 37 weeks) as the largest contributor to CS rates. Alsulami et al. (24) reported a CS rate of 27.5% at King Abdul-Aziz Medical City in Jeddah, with Group 5 accounting for 36.2% of CS deliveries. Similarly, AlBasri et al. (2025) found that Group 5 contributed 54% to the CS rate at King Abdulaziz University Hospital, with 63.65% of CS cases attributed to a history of CS. These findings align with global trends, where repeat CS significantly drive overall rates (26). Alsulami et al. (2024) noted that Groups 1–4 (low-risk groups) collectively accounted for 37.8% of CS cases, with Group 2 contributing 12.9% and Group 3 (multiparous, no previous CS, single cephalic, ≥ 37 weeks, spontaneous labour) contributing 9.2%. These groups represent opportunities for intervention as they include low-risk women who may benefit from enhanced labour support to avoid unnecessary CS.

The Maternity and Children’s Hospital (MCH) is one of the largest tertiary care hospitals in Al-Qassim, Saudi Arabia; therefore, there is a need to conduct a study on various indications of sections according to WHO Robson’s classification and analyse the rate among different groups. This study is crucial for understanding the specific indications and trends in CS deliveries, providing insights that can enhance clinical practice and improve maternal and neonatal health. This will not only provide an overview of the obstetric profile of the women presented here but also allow us to evaluate the service provided to them in terms of rational indications for CS. In addition, the study will try to explain using multinomial regression how hypertensive disorders, gestational diabetes, obesity, antepartum haemorrhage, chorioamnionitis, and foetal conditions, such as intrauterine growth restriction (IUGR) or abnormal amniotic fluid volume, influence group assignment and CS likelihood.

Institutional protocols and guidelines should be developed based on this analysis.

The following is the WHO Robson’s TGCS (3) See Appendix

2. OBJECTIVE

The aim of the study was (1) to evaluate the overall rate of CS deliveries in MCH in Qassim based on the Robson Classification System (2) to identify the most common Robson classification groups contributing to CS (3) to analyze the maternal and fetal characteristics associated with high-risk CSs in different Robson’s groups (4) to propose targeted recommendations for reducing unnecessary CSs by addressing specific Robson groups

3. PATIENTS AND METHODS

Participants

This study was conducted at the Obstetrics and Gynaecology, Department of the MCH, Al-Qassim.The study population consisted of gravid women (nulliparous and multiparous) with or without a history of CS deliveries receiving care services at the MCH in Al-Qassim.

Procedure and ethical considerations

This study was approved by the Institutional Review Board and Ethics Research Committee, Ministry of Health, Qassim Region (number: 607/46/5557).

Measures

Demographic characteristics like age, parity, clinical presentation, onset of labour were included

Statistical analysis

Data were collected by reviewing medical records and a specific predesigned proforma that included all relevant information, such as demographic characteristics and risk factors based on history, examination, and ultrasound findings. Women delivered at Al-Qassim during the study period. The collected data were anonymised by removing all identifiers and stored securely in a password-encrypted drive. Data analysis was performed using SPSS version 27 at a 95% confidence interval, and the results are presented as narratives, tables, and figures.

4. RESULTS

Demographic and Clinical Characteristics

In total, 1,809 deliveries were recorded at the MCH. Of these, 835 were CSs and 974 were normal vaginal deliveries. This yielded a total CS rate of 46.15%. A total of 835 women who underwent CS were included in this study, with 63.9.0% (n = 534) reporting a history of CS. Most participants were aged 25–34 years (52.9%, n = 442), with a substantial proportion aged 35–39 years (28.6%, n = 239), and those aged ≥ 40 years comprised 12.0% (n = 100) of the participants. Most women were multiparous (80.1%, n = 669), with only 19.9% (n = 166) being nulliparous with most reported deliveries occurring at term (≥ 37 weeks’ gestation; 82.9%, n = 692), and only 14.4% (n = 120) recording preterm deliveries between 32 and 36 weeks(Table-1)

Table 1. Women’s characteristics (n = 835).

Demographics Characteristic/variable	Count (%)
Maternal age < 18 18–24 25–34 35–39 > 40	2 (0.2) 52 (6.2) 442 (52.9) 239 (28.6) 100 (12.0)
Parity Nulliparous > 1	166 (19.9) 669 (80.1)
Gestational age < 28 weeks 28–31 weeks 32–36 weeks > 37	6 (0.7) 17 (2.0) 120 (14.4) 692 (82.9)
Previous caesarean section Yes No Missing	534 (64.0) 299 (35.8) 2 (0.2)
Presentation Cephalic Breech Others Missing	726 (86.9) 103 (12.3) 4 (0.5) 2 (0.2)
Multiple pregnancy Yes No	42 (5.0) 793 (95.0)
Mode of onset of labour Spontaneous Induction Pre-labour caesarean Missing	213 (25.5) 53 (6.3) 568 (68.0) 1 (0.1)
The failed progress of labour Failed IOL Missing	74 (8.9) 761 (91.1)
Maternal medical disorders Pregestational diabetes Gestational diabetes Pregestational hypertension Gestational hypertension Preeclampsia not severe Preeclampsia severe Obesity: BMI > 27.5 kg/m2 Cardiac disease Oligohydramnios Polyhydramnios IUGR APH/major placenta previa Severe anaemia (haemoglobin level < 7 g/dL) Chorioamnionitis	16 (1.9) 50 (5.9) 12 (1.4) 11 (1.3) 13 (1.6) 17 (2.0) 264 (31.6) 1 (0.1) 25 (3.0) 22 (2.6) 29 (3.5) 34 (4.1) 5 (0.6) 2 (0.2)
Indications for CS Foetal distress/abnormal CTG Past CS Breech/abnormal lie Hypertension, preeclampsia, eclampsia IUGR APH/major previa Prelabour diagnosis of CPD h/o subfertility or BOH Maternal request Multiple pregnancies DM Thick meconium Preterm Others Missing	107 (12.8) 371 (44.4) 88 (10.5) 27 (3.2) 11 (1.3) 28 (3.4) 1 (0.1) 14 (1.7) 79 (9.5) 17 (2.0) 1 (0.1) 17 (2.0) 1 (0.1) 13 (1.6) 60 (7.2)
Robson Classification System Nulliparous women, single cephalic foetus, > 37 weeks, spontaneous labour Nulliparous women, single cephalic foetus, > 37 weeks, induced labour or caesarean section performed before labour onset Multiparous without previous uterine scar, single cephalic foetus > 37 weeks in spontaneous labour Multiparous without previous uterine scar, single cephalic foetus > 37 weeks, with induced labour or caesarean section performed before labou All multiparous women with at least one previous scar, with a single cephalic foetus, > 37 weeks of gestation All nulliparous women with a single breech pregnancy All multiparous women with single breech foetus, including women with previous uterine scars All women with multiple pregnancies, including women with previous uterine scars All women with a single pregnancy with a transverse or oblique lie presentation, including women with previous uterine scars All women with single cephalic pregnancy < 37 weeks of gestation, including women with previous scars	44 (5.3) 65 (7.8) 30 (3.6) 38 (4.6) 428 (51.3) 21 (2.5) 71 (8.5) 42 (5.0) 3 (0.4) 93 (11.1)

Cephalic presentation was predominant (86.9%, n = 726), with breech presentation noted in 12.3% (n = 103) of the participants. Multiple pregnancies occurred in 5.0% (n = 42) of the participants. Regarding labour onset, 68.0% (n = 568) underwent pre-labour CS, 25.5 % (n = 213) had spontaneous labour, and 53 (6.3%) had induced labour. Failed induction of labour was reported in 8.9% (n = 74) of the patients, indicating a significant proportion of unsuccessful labour induction attempts.(Table-1)

Obesity (body mass index [BMI] > 27.5 kg/m²) was the most prevalent maternal condition, affecting 31.6% (n = 264) of the participants. Gestational diabetes was reported in 5.9% (n = 50) of the patients, and IUGR affected 3.5% (n = 29). Antepartum haemorrhage or major placenta previa was noted in 4.1% (n = 34) of the participants, whereas preeclampsia, both non-severe (1.6%, n = 13) and severe (2.0%, n = 17), was less common but clinically significant because of its potential for maternal and foetal complications.(Table-1)

The most common indication for CS was a history of previous CS (44.4%, n = 371), followed by foetal distress or abnormal cardiotocography (12.8%, n = 107), and breech or abnormal lie (10.5%, n = 88). Preeclampsia/eclampsia contributed to 3.2% (n = 27) of the cases, and antepartum haemorrhage or major placenta previa contributed to 3.4% (n = 28). Notably, maternal requests accounted for 9.5% (n = 79) of the indications for CS, suggesting a significant influence of patient preference on the delivery mode.(Table-1)

Among the 835 CS cases analysed under the Robson Classification System, Group 5 (multiparous women with at least one previous CS, single cephalic foetus, ≥ 37 weeks gestation) accounted for most CS deliveries (n = 428, 51.3%), whereas Group 9 (asll women with a single pregnancy with a transverse or oblique lie presentation, including women with previous uterine scars) accounted for the least (0.4%).(Table-1)

Multinomial logistic regression

A multinomial logistic regression analysis was performed to examine the relationship between Robson Group membership (10 groups, with ‘all women with single cephalic pregnancy < 37 weeks gestation, including women with previous scars’ as the reference category) and the predictor variables maternal age, gestational age, parity, previous CS, presentation, multiple pregnancy, mode of onset of labour, pregestational diabetes, gestational diabetes, hypertensive disorders of pregnancy, obesity (BMI > 27.5 kg/m²), emergency vs. elective delivery, maternal cardiac disease, oligohydramnios, polyhydramnios, IUGR, antepartum haemorrhage/major placenta previa, severe anaemia, and chorioamnionitis. The model was statistically significant, indicating that it was able to distinguish effectively between the Robson groups based on the predictor variables (χ² [234] = 1797.45, p< 0.001). The model demonstrated good explanatory power, with a Nagelkerke pseudo-R² value of 0.918.(Table-2)

In several comparisons between specific Robson groups and the reference category, the key predictors showed significant associations. Gestational age, parity, previous CS, presentation, multiple pregnancies, and mode of labour onset were frequently significant predictors across different group comparisons. Specifically, for the comparison between ‘nulliparous women, single cephalic foetus, > 37 weeks, spontaneous labour’ (Group 1) and the reference category, gestational age and mode of onset of labour were significant predictors. Each week, an increase in gestational age was associated with a large increase in the likelihood of belonging to Group 1 (B = 5.15, p < .001, Exp[B] = 171.76, 95% confidence interval [CI]: 18.97–1554.86). Spontaneous labour (compared with induced labour or CS before labour) was also associated with a higher likelihood of belonging to Group 1 (B = 3.05, p < .001, Exp[B] = 21.05, 95% CI: 5.01–88.51). Higher parity decreased the likelihood of belonging to Group 1 (B = –4.53, p = .030, Exp[B] = 0.011, 95% CI:0 .000–0.641).(Table-2)

For the comparison between ‘multiparous without previous uterine scar, single cephalic foetus > 37 weeks in spontaneous labour’ (Group 3) and the reference category, both gestational age and parity were significant predictors. Each week, an increase in gestational age was associated with a large increase in the likelihood of belonging to Group 3 (B = 5.32, p <0 .001, Exp[B] = 204.70, 95% CI: 19.79–2117.10). Higher parity also significantly increased the likelihood of belonging to Group 3 (B = 5.77, p =0 .009, Exp[B] = 319.20, 95% CI: 4.29–23738.93). For the comparison between ‘all multiparous women with at least one previous scar, with a single cephalic foetus, > 37 weeks gestation’ (Group 5) and the reference category, gestational age was a significant predictor. Each week, an increase in gestational age was associated with a large increase in the likelihood of belonging to Group 5 (B = 4.95, p < 0.001, Exp[B] = 141.48, 95% CI: 51.62–387.79). For the comparison between ‘all nulliparous women with a single breech pregnancy’ (Group 6) and the reference category, presentation (breech vs. cephalic) was a significant predictor. Having a breech presentation (compared with a cephalic presentation) was associated with a significantly higher likelihood of belonging to Group 6 (B = 7.05, p =0 .001, Exp[B] = 1155.90, 95% CI: 1155.90–1155.90). For the comparison between ‘all women with multiple pregnancies, including women with previous uterine scars’ (Group 9) and the reference category, multiple pregnancy was a significant predictor. Being part of a multiple pregnancy (compared with a singleton) was associated with an extremely large increase in the likelihood of belonging to Group 9 (B = 22.49, p =0 .696, Exp[B] = 5869096042.05, 95% CI: 6.658E-40–5.174E+58).(Table-2)

Several other predictors and group comparisons were also significant. Variables such as maternal age, pregestational diabetes, gestational diabetes, hypertensive disorders of pregnancy, obesity, emergency vs. elective status, maternal cardiac disease, oligohydramnios, polyhydramnios, IUGR, APH/major placenta previa, severe anaemia, and chorioamnionitis were not significant predictors in most comparisons, although they were retained in the full model. Some parameter estimates showed signs of model-fitting problems, suggesting potential issues.(Table-2)

5. DISCUSSION

The overall CS rate at the MCH, Al-Qassim, was 46.15% during the study period; this prevalence was higher than the WHO recommendations of approximately 10–15% of all deliveries conducted in a country. Elective CS accounted for 54.5% of the total cases, whereas 45.5% were emergency cases. These findings are consistent with those of Chaudhary et al. and Alsulami et al. (23 and 24), who reported CS rates exceeding WHO recommendations. The Robson classification groups that contributed the greatest to the CSs at MCH were Group 5 (multiparous women with at least one previous CS, single cephalic foetus, ≥ 37 weeks gestation), accounting for 51.3% of the CS deliveries conducted within the study period. These findings are concordant with those of Alsulami et al. (24), who found that Class 5 had the largest percentage of patients undergoing CS (36.2%) in King Abdul-Aziz Medical City, Jeddah, Saudi Arabia.

Table 2. Multinomial logistic regression: significant predictors of group membership.

Groups	Predictor	B	SE	Wald χ2	df	p	Exp(B)	95% CI for Exp(B)
Group 1	Gestational age	5.146	1.124	20.96	1	<.001	171.76	[18.97–1554.86]
	Parity	–4.533	2.086	4.72	1	.030	0.01	[0.00–0.64]
	Previous caesarean section (yes)	–12.35	1.933	40.82	1	< .001	0.00	[0.00–0.00]
	Mode of onset of labour (Spont.)	3.047	0.733	17.29	1	< .001	21.05	[5.01–88.51]
Group 2	Gestational age	4.780	1.149	17.30	1	< .001	119.08	[12.51–1132.77]
	Parity	–3.884	1.881	4.264	1	.039	.021	[.001–.821]
	Previous caesarean section (yes)	–14.590	1.765	68.30	1	< .001	4.6E-7	[1.44E-8–1.47E-5]
Group 3	Gestational age	5.322	1.192	19.93	1	< .001	204.70	[19.79–2117.10]
	Previous caesarean section (yes)	–11.234	1.337	70.63	1	< .001	1.32E-5	[9.62E-7–.000]
	Mode of onset of labour (Spont.)	3.212	.777	17.08	1	< .001	24.83	[5.41–113.90]
Group 4	Gestational age	5.046	1.262	15.98	1	< .001	155.43	[13.09–1845.14]
	Previous caesarean section (yes)	–14.885	1.316	127.99	1	< .001	3.43E-7	[2.60E-8–4.52E-6]
	Hypertensive disorders of pregnancy	4.185	1.950	4.61	1	.032	65.70	[1.44–3000.30]
Group 5	Gestational age	4.952	.514	92.66	1	< .001	141.48	[51.62–387.79]
	APH/major placenta previa	–2.217	.937	5.60	1	.018	.11	[.017–.684]
Group 6	Gestational age	3.616	1.092	10.98	1	< .001	37.20	[4.38–316.02]
	Parity	–6.138	1.990	9.51	1	.002	.002	[4.37E-5–.107]
	Previous caesarean section (yes)	–12.897	1.802	51.21	1	< .001	2.51E-6	[7.32E-8–8.57E-5]
Group 7	Gestational age	4.318	1.135	14.48	1	< .001	75.06	[8.12–694.03]
	Previous caesarean section (yes)	–12.877	1.780	52.32	1	< .001	2.56E-6	[7.80E-8–8.37E-5]
Group 9	Presentation	–210.497	29.139	52.19	1	< .001	3.82E-92	[6.02E-117–2.43E-67

This study found that medical indications were the predominant reasons for CS at the MCH. These findings are consistent with those of Alabdullah et al. (22), who showed that CS was mainly approved for medical reasons and that previous CS scars accounted for the majority of all CSs conducted, which is consistent with the study conducted by AlBasri et al. (25). Compared with other countries in the UAE, in Dubai, Groups 5, 8, and 9 were the major contributors to CS (27)28, whereas Groups 5, 1, and 2 were the major contributors (28), with Group 5 being the most prominent in both countries. Beyond the Middle East, studies share the same findings as the present study, with Group 5 being a major contributor to CS in Lebanon (22).

This study found that maternal and fetal characteristics, such as prior CS, hypertensive disorders of pregnancy, malpresentation (breech or transverse lie), multiple gestations, preterm delivery, and antepartum complications, such as placenta previa and chorioamnionitis, were strongly associated with high-risk CSs across specific Robson groups, particularly Groups 5 (multiparous, cephalic, term, previous CS), 7 (multiparous, breech), 9 (multiparous, transverse/oblique lie), and 10 (preterm, cephalic). The findings of this study are consistent with those of Alsulami et al. AlBasri et al. (24,25), who also identified Group 5 as the largest contributor to CS rates in Saudi Arabia, accounting for over half of all CS deliveries, with prior CS being the dominant indication. Similarly, the high contribution of Groups 7 and 9 aligns with that of Parveen et al. (16), who found that malpresentation and multiparity significantly influenced CS decisions. Additionally, the strong association between preterm caesarean delivery (Group 10) and maternal complications echoes the findings of Wahabi et al. (29), who identified these comorbidities as key predictors of emergency CSs. However, unlike studies that primarily used descriptive analyses of Robson group distributions, this study used multinomial logistic regression to quantify the independent effects of multiple maternal and foetal risk factors across all ten Robson groups, allowing for a more nuanced understanding of how specific conditions drive classification and surgical decision-making. This analytical advancement provides a stronger basis for targeted interventions aimed at reducing nonessential CSs, particularly in high-volume groups, where modifiable factors can be optimised.

6. CONCLUSION

This study provides insights into the high prevalence rates of CS, primarily escalated by previous CS scarring and maternal obesity. The higher prevalence rates of CS deliveries in Group 5 suggest that efforts to reduce primary CS, particularly among nulliparous women, have the greatest long-term impact. Additionally, strategies to reduce CS deliveries, such as promoting vaginal birth after CS when safe, implementing second-opinion protocols before repeat CS, and auditing low-risk groups (Robson Groups 1–4), would be impactful in reducing the total number of CS deliveries, thereby significantly reducing the overall prevalence.

Patient Consent Form:

Not needed as it was a retrospective study.

Author’s Contribution:

Zaheera Saadia designed, analyzed the data and wrote the manuscript. Khalid Nasrallah helped in writing the results. Rabia bibi, Reema Alharbia, Jenan Alqurishi Najd Alanazi, Ajwan Alqurishi collected the data and helped in literature review. All authors approved the final manuscript.

Conflicts of interest:

There are no conflicts of interest.

Financial support and sponsorship:

None.