Background/Aim. The global rise in cesarean section (CS) rates represents a significant clinical and public health concern. Long-term monitoring of local trends provides important insight into healthcare system organization and evolving obstetric practice. The aim of the study was to analyze temporal trends in total deliveries, CS rates, and major indications for CS in a secondary care hospital over a 20-year period. Methods. A retrospective descriptive study was conducted using anonymized hospital records from General Hospital in Gračanica, Bosnia and Herzegovina, covering the period from 2005 to 2025. Annual data on total deliveries and CS were collected. CS rates were calculated for each year, and temporal trends were assessed using descriptive and trend analysis. In addition, a subanalysis of CS indications from 2015 to 2025 was performed. Results. A marked decline in total deliveries was observed, decreasing from 464 in 2005 to 214 in 2025. At the same time, CS rates demonstrated a consistent upward trend, increasing from 13.6% in 2005 to 29.4% in 2025. The peak CS rate was recorded in 2019 (31.9%), while a similarly high rate was observed in 2021 (31.8%). Lower rates were observed in 2022 and 2023, followed by an increase in the subsequent 2 years. The most frequent indication for CS was previous CS (55.5%), followed by hypertensive disorders in pregnancy (11.6%) and breech presentation of the fetus (11.5%). Conclusion. The simultaneous decline in birth rates and increase in CS rates reflects the combined impact of demographic changes and evolving healthcare system capacity, including improved access to operative obstetric care. The predominance of repeat CS as the leading indication further emphasizes the importance of careful evaluation of primary cesarean deliveries and adherence to evidence-based clinical guidelines.