Our experience with the 10-Group Robson classification system in Egypt to analyse its high caesarean section rate

Caesarean section (CS) is the most commonly used surgical intervention. A caesarean section rate of 10-15% is associated with a notable decline in maternal and neonatal mortality rate (MMR, NMR). According to the latest evidence, the maternal and neonatal morbidity and mortality secondary to caesarean section are much more devastating in low and middle-income countries due to the limited resources.

Egypt has the third-highest CSR globally after Brazil (55%) and Dominican Republic (58%). The proportion of births by CS in Egypt has increased from 22% in 2000 to 52% in 2014. With such extreme trends, women exposed to CS are at increased risk of complications in their subsequent pregnancy, including abnormal placentation, uterine rupture, blood transfusion, hysterectomy, and death. The financial impact of such a high number of CSS poses a serious threat to Egyptian healthcare expenditure. In 2014, overuse of CS deliveries cost the Egyptian health care system 929,664,000 Egyptian pounds.

Like many developing countries, Egypt's health care facilities have no standardized, internationally accepted classification system to monitor and compare facility-based CS rates in a consistent and action-oriented manner. We used the 10 –Group Robson classification system (TGRCS) in twelve tertiary hospitals of Egypt in 2019 for three months to analyse, assess and compare the CSRs. The 10 Group Robson classification is a global standard classification system recommended by the World Health Organization (WHO) to analyse CSRs. It classifies women in 10 groups based on their obstetric characteristics (parity, previous CS, gestational age, onset of labour, fetal presentation and number of fetuses) without needing the indication for CS. 

Results showed an average CSR of 62%. Group 5 (women with previous CS) was the most significant contributor (57%) to the overall CSR, followed by group10 (preterm births, 13.7%) and group 2 (primipara with induction of labour/ pre-labour CS, 7.9%).

We found that the Robson classification can be implemented effectively in resource limited settings. The careful selection of women and balancing their risks and benefits for the trial of labour after one CS can reduce the risk of having a repeat CS. Qualitative research is required in future to explore the underlying factors for CS in identified groups. 

The full article is under review for publication.

You can access other related articles on our similar work in Egypt with the following references:

1. Jadoon, B., Mahaini, R. & Gholbzouri, K., 2019. Determinants of over and underuse of caesarean births in the Eastern Mediterranean Region: an updated review. Eastern Mediterranean Health Journal, 25(11), pp.837–846.
2. Jadoon, B. et al., 2019. Analysis of the caesarean section rate using the 10-Group Robson classification at Benha University Hospital, Egypt. Women and birth: journal of the Australian College of Midwives.

For further information, please email Dr Bismeen Jadoon