Sexual and reproductive health

A systematic review of the Robson Classification for caesarean section

What works, doesn’t work and how to improve it

Surgeons preparing patient for cesarean section

Caesarean section without medical indication increases risk of short-term adverse outcomes for mothers

2004–2008 WHO Global Survey on Maternal and Perinatal Health

Caesarean section (CS) rates continue to increase worldwide, particularly in middle- and high-income countries without evidence indicating substantial maternal and perinatal benefits from the increase and some studies showing negative consequences for maternal and neonatal health. The lack of a standardized internationally-accepted classification system to monitor and compare CS rates in a consistent and action oriented manner is one of the factors that has hindered a better understanding of this trend.

In 2011, a systematic review of available classifications for CS concluded that the Robson classification (also called the 10-group classification) would be in the best position to fulfil this gap. Proposed in 2001, the Robson classification is a system that classifies women into 10 groups based on their obstetric characteristics (parity, previous CS, gestational age, onset of labour, fetal presentation and the number of fetuses). Since the system can be applied prospectively and its categories are totally inclusive and mutually exclusive, every woman that is admitted for delivery can be immediately classified based on these few basic characteristics which are usually routinely collected worldwide in obstetric wards.

Despite the lack of any official endorsement or formal guidelines, the international use of this classification is increasing rapidly and spontaneously. Our recently published article presents the results of a systematic review conducted to synthesize the experience of users in the implementation of this classification and their recommendations for its use. Users valued that this classification, which does not use indication for the CS, allows for the creation of subdivisions in each group and can improve analysis of local practices. Subdivisions have been proposed for each of the 10 groups but group 5 (women with previous CS) is the group receiving the largest number of suggestions. The creation of group “99” to include women with missing data and thus unable to be classified in any of the 10 groups is an important and relevant contribution. Lack of definitions or consensus on the core variables and the maintaining of high quality data are important challenges encountered by users.