Caesarean section Robson classification, complications, and lessons learned in a rural hospital in Walikale, North Kivu, Democratic Republic of Congo: a cross-sectional study.

Background: Globally rising caesarean section (CS) rates have resulted in more women with a scarred uterus. In low-resource, high-fertility settings, this likely contributes to a growing number of high-risk pregnancies and births. Exploring and understanding this trend in low-resource settings is essential to reduce maternal and perinatal mortality globally. Objective: This study aimed to assess CS practices in Walikale, eastern Democratic Republic of Congo (DRC), using the Robson classification, clinical indications, maternal and perinatal complications, and quality of care, to improve CS decision-making and clinical outcomes. Study Design: A cross-sectional study was conducted at the General Referral Hospital of Walikale, North Kivu, DRC, from January 1 to March 31, 2024. Data from all births were reviewed, and clinical case reviews were performed systematically for each CS by a team of health care providers. Descriptive statistics were used for analysis. Results: The CS rate was 15.7%, with 136 CS of 868 births. Women in Robson group 5 (previous CS, term, cephalic presentation), accounted for 50% of all CS (68/136). Among CS in Robson groups 6 to 10 (malpresentation, twins, preterm), 65.6% (21/32) were also performed in women with a previous CS. Vaginal birth after CS (VBAC) rates were high: 71.2% (79/111) after one and 50.0% (23/46) after two previous CS. Among women with a previous CS (191/868, 22.0% of the population), uterine rupture occurred in 5.8% (11/191) and abnormally invasive placenta in 3.7% (7/191). Surgical site infections occurred in 7.4% (10/136) of CS. Perinatal mortality was 60 per 1000 births (53/886 total births). Case reviews showed that 9.6% (13/136) of CS were performed "too late" and 24.3% (33/136) "too soon." Positive findings included high antenatal care attendance and short decision-to-CS intervals. Recommendations following from case review included strengthening clinical supervision and training health workers, team decision-making for CS with relative indications, ensuring access to the hospital, medication, blood, and contraception, especially for women with prior CS. Conclusion: In this conflict-affected, high-fertility, low-resource context, the CS rate is rising as well as the proportion of women with a scarred uterus. The majority of CS are performed in women with a previous CS. VBAC rates are notably high, though both VBAC and multiple repeat CS carry important safety considerations. Applying the Robson classification is challenging in low-resource settings, where gestational age is often unknown. To optimize CS care and reduce adverse outcomes, it is crucial to prevent the first unnecessary CS, ensure timely and appropriate indications through context-adapted guidelines, clinical supervision, and routine case reviews, and strengthen both basic and comprehensive antenatal and obstetric care.