A root cause analysis of increasing caesarean section rates in a tertiary care private hospital in North India


  • Bela Makhija Department of Obstetrics and Gynecology, Max Smart Super Specialty Hospital, New Delhi, India
  • Deepika Verma Department of Obstetrics and Gynecology, Max Smart Super Specialty Hospital, New Delhi, India
  • Asif Mustafa Department of Obstetrics and Gynecology, Max Smart Super Specialty Hospital, New Delhi, India




Caesarean delivery on maternal request, Lower segment caesarean section, Robson’s criteria, Trial of labour after caesarean, Vaginal birth after caesarean section


Background: Increase in the incidence of caesarean section is a matter of concern worldwide. Robson’s criteria which is universally accepted now as a way for calculating caesarean rates takes into account only the obstetrical consideration, however, it is noteworthy that many socioeconomic and cultural factors also have a role to play. This study takes into account both Robson’s criteria and common socio-cultural factors which lead to increased caesarean rates with an attempt to suggest ways to curtail this trend.

Methods: The study was a hospital based cross-sectional study at a private tertiary care hospital in New Delhi. 1200 consecutive live births after 34 weeks of gestation were analysed over a period of one year.

Results: LSCS was the most common mode of delivery 733 (61.1%). 329 (27.4%) had induced labour of which 260 (76.2%) had LSCS. 333 women had elective LSCS. Rates of CDMR were 185 (25.2%) which is very significant. As per Robson’s criteria maximum number of women (318) were in group 2, of which 226 (71.1%) underwent caesarean section.

Conclusions: High caesarean rates can be attributed to a multitude of factors. Robson’s criteria are an effective way for analysis of obstetric indications. Other added factors include comorbidities, CDMR, fear of litigations, etc which were analysed.


Tampakoudis P, Assimakopoulos E, Grimbizis G, Zafrakas M, Tampakoudis G, Mantalenakis S. Cesarean section rates and indications in Greece: data from a 24-year period in a teaching hospital. Clin Experim Obst Gynecol. 2004;31(4):289-92.

Lee SI, Khang YH, Lee MS. Women’s attitudes toward mode of delivery in South Korea: a society with high cesarean section rates. Birth. 2004;31(2):108-16.

Martin JA, Hamilton BE, Sutton PD, Ventura SJ, Menacker F, Kirmeyer S, Munson ML. Births: final data for 2005. National Vital Statistics Reports. 2007;56(6):1-3.

Thomas J, Callwood A, Brocklehurst P, Walker J. The national sentinel caesarean section audit. Int J Obst Gynaecol. 2000;107(5):579-80.

Marathe S, Mukadam R. Profiteering hospitals are driving alarming rise in C-section deliveries in India. Available at http:// rchiips.org/ NFHS/ factsheet _NFHS-4.shtml. Accessed on 12th January 2019.

Belizán JM, Showalter E, Castro A, Bastian H, Althabe F, Barros FC, et al. Rates and implications of caesarean sections in Latin America: ecological study Commentary: all women should have a choiceCommentary: increase in caesarean sections may reflect medical control not women's choice Commentary:“health has become secondary to a sexually attractive body”. British Med J. 1999;319(7222):1397-402.

NHS Institute for innovation and improvement 2006. Delivering quality and value focus on: caesarean section. Available at https:// www. Qualitasc onsortium. com/i ndex. cfm/ reference-material/ delivering -value -quality/focus-on-csection/. Accessed on 12 January 2019.

Sexual and reproductive health. Department of Reproductive Health and Research (RHR) including the Special Programme HRP: A systematic review of the Robson Classification for caesarean section. WHO. Available at http://www.who.int/reproductivehealth/topics/maternal_perinatal/robson-classification/en/ Aceessed on 15 March 2019.

IBM. IBM SSPS software. IBM Corp (Released 2011). IBM SPSS Statistics for Windows, Version 20.0. Armonk, NY: IBM Corp. Available at www.ibm.com/products/ssps-statistics. Accessed on 14 March 2019.

Seffah JD, Bonsaffoh AK. Vaginal birth after a previous caesarean section: current trends and outlook in Ghana. J West Afr Col Surg. 2014;4(2):1.

Subhashini R, Uma N. Changing trends in Cesarean delivery. IAIM. 2015;2(3):96-102.

Ray A, Jose S. Analysis of caesarean-section rates according to Robson's ten group classification system and evaluating the indications within the groups. Int J Reprod Contra Obst Gynecol. 2017;6(2):447-51.

Liu S, Russen D, Joseph KS, Liston R, Kramer MS, Wen SW, et al. Recent trends in cesarean delivery rates and indications for cesarean delivery in Canada. J Obstet Gynaecol Can. 2004;26(8):735-42.

Betran PA, Gulmezoglu AM, Robson M, Merialdi M, Souza PJ, Widmer M, et al. WHO global survey on maternal and perinatal health in latin America: classifying cesarean sections. Reprod Health. 2009;6:18.

Emma L, Lundsberg L, Belanger K, Pettker VM, Funai EF, Illuzzi JL. Contributing indications to rising cesarean delivery rates. Obstet Gynecol. 2011:118(1):29-38.

Kazmi T, Saiseema S, Khan S. Analysis of cesarean section rate- according to Robson’s 10-group classification. Oman Med J. 2012;27(5):415-7.

Dhodapkar SB, Bhairavi S, Daniel M, Chauhan RC. Analysis of cesarean sections according to Robson’s ten-group classification system at a tertiary care teaching hospital in south India. Int J Reprod Contracept Obstet Gynecol. 2015;4:745-9.

Liu Y, Li G, Wang X, Ruan Y, Zou L, Zhang W. A descriptive analysis of the indications for cesarean section in mainland China. BMC Preg Child. 2014;14:410.

Ramesh B, Ravi V, Archana HK. Analysis of increasing cesarean section rates using 10 group classification system. J Evid Based Med Healthc. 2016;3(61):3323-7.

Koteshwara S, Sujatha MS. Analysis of cesarean section rates using Robsons ten group classification: the first step. Int J Reprod Contracept Obstet Gynecol. 2017;6:3481-5.

Kumari BS, Rao GV. Study on factors influencing caesarean section delivery in urban field practice area of Kamineni Institute of Medical Sciences, Narketpally, Nalgonda, India. Int J Repro Contracep Obst Gynecol. 2017;6(7):3129-33.

Yadav R, Maitra N. Examining cesarean delivery rates using the robson’s ten-group classification. J Obst Gynecol India. 2015;66(1):1-6.

Jacob KJ, Jayaprakash M, Hibina KP. TMC (Thrissur Medical College) modified Robson criteria for cesarean sections. Int J Reprod Contracept Obstet Gynecol. 2017;6(11):5038-43.

Agarwal M, Verma M, Garg A. Changing trends in cesarean delivery: rate and indications. Int J Reprod Contracept Obstet Gynecol. 2016;5:3522-4.

Dhillon BS, Chandhiok N, Bharti S, Bhatia P, Coyali J, Das MC, et al. Vaginal birth cesarean section (VBAC) versus emergency repeat cesarean section at teaching hospitals in India: an ICMR task force study. Int J Reprod Contracept Obstet Gynecol. 2014;3(3):592-7.

Rosales CF, Lamb F, Ayuk P. Lower Caesarean section rates in women induced for obstetric cholestasis. Arch Dis Childhood Fetal Neonatal Edition. 2010;95(1):51-5.

Seligman LC, Duncan BB, Branchtein L, Gaio DS, Mengue SS, Schmidt MI. Obesity and gestational weight gain: cesarean delivery and labor complications. Revista De Saude Publica. 2006;40:457-65.

Cunningham FG, Leveno KJ, Bloom SL, Dash JS, Hoffman BL, Casey BM, Spongy CY; Williams Obstetrics, 25th Ed. McGraw-Hill Education; 1247-1252,1304.






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