Implementation of Robson’s ten-group classification system for cesarean section rates at a tertiary university hospital in Egypt: a prospective study

BACKGROUND: Egypt has one of the highest reported cesarean section (CS) rates globally. Aggregate CS rates alone, however, do not identify which obstetric populations contribute most to CS use or whether interventions are clinically appropriate. The Robson Ten-Group Classification System (TGCS) provides a standardized method for institutional audit and benchmarking. METHODS: We conducted a prospective observational study at El-Shatby Maternity University Hospital, Alexandria, Egypt, from September 1, 2021, to March 1, 2022. All women admitted for delivery at ≥ 28 weeks' gestation and/or fetal weight > 500 g were included. Women were categorized into Robson groups using the six core obstetric variables. Proportions and 95% confidence intervals (CIs) were calculated for the main estimates. RESULTS: Among 5682 deliveries, 3405 were by CS (59.9%, 95% CI 58.6-61.2). Group 5 was the largest group (1742/5682, 30.7%) and contributed 47.6% of all CSs, with a group-specific CS rate of 93.1% (95% CI 91.8-94.2). Group 10 comprised 16.7% of the obstetric population and contributed 20.6% of all CSs; its group-specific CS rate was 73.9% (95% CI 71.1-76.6). Groups 2 and 4 had CS rates of 47.1% and 50.4%, respectively. Group 1 and Group 3 had lower group-specific CS rates of 14.5% and 11.9%, respectively. Vaginal birth after cesarean (VBAC) occurred in 126 cases (2.2% of all deliveries). CONCLUSIONS: This prospective audit established a standardized Robson baseline for a high-volume Egyptian tertiary maternity unit. The high overall CS rate reflected a large Group 5, high CS rates in modifiable Groups 2 and 4, and a substantial contribution from Group 10. The findings identify priorities for future audit, including prevention of unnecessary primary CS, assessment of trial of labor after cesarean (TOLAC) eligibility and counseling, and review of preterm CS decision-making. They should not be interpreted as proving that all observed CSs were unnecessary.