Cesarean sections in Suriname using Robson classification: a two-year nationwide cross-sectional study

Abstract Background – Cesarean Section (CS) rates are increasing concerningly. Optimizing CS performance is a global health priority, given the maternal and perinatal morbidity and mortality associated with both underuse and overuse. This nationwide study in Suriname aims to (1) determine the national, facility-based CS rate and explore which women are at highest risk and (2) use the WHO Robson classification to enhance understanding drivers and outcomes of CS to develop tailored interventions. Methods – An observational, cross-sectional study in Suriname, using nationwide birth registry data that included all hospital births in 2020 and 2021. We used multivariate logistic regression analysis to assess maternal and perinatal characteristics associated with CS. We described caesarean births according to the Robson-10 classification and used descriptive statistics to analyze CS frequencies and neonatal outcomes. Results – We analyzed the 18,917 women who gave birth in Surinamese hospitals, with an overall 23.9% CS rate (n=4522). The highest CS rates were seen among women with a previous CS(69.3%, aOR 16.2, 95% CI 14.4 – 18.2), BMI > 40 (47.0%, aOR 5.1, 95% CI 4.0 – 6.5), newborn with a birth weight above 4000 grams (37.3%, 2.2, 95% CI 1.6 – 3.0) and women giving birth at hospital IV (38.5%, aOR 1.8, 95% CI 1.6 – 2.0). Hindustani women were more likely to give birth by CS compared to maroon women (aOR 1.6, 95% CI 1.4 – 2.0). Robson group 5 (i.e. multiparous, term women with a previous CS and cephalic presentation), contributed to 30.5% of the CS cases (n=1378). Robson group 2 and 4 (i.e. pre-labor CS, or CS after induction, among term women without previous CS and cephalic presentation) contributed to 21.8% (n=985) of all CS performed. Robson group 1 and 3 (i.e. during spontaneous labor CS among term women without previous CS and cephalic presentation) accounted for 23.3% (n=1052) of the CS cases. Conclusion – The CS rate in Suriname is 24%, with substantial intra-country and inter-hospital variations. These disparities underscore the need for targeted interventions addressing both overuse and underuse of CS. Preventative measures should prioritize promoting safe VBAC, preventing first-time CS and ongoing monitoring of trends and regular case audits.