Abstract
BackgroundApplying the Robson classification to all births in Brazil, the objectives of our study were to estimate the rates of caesarean section delivery, assess the extent to which caesarean sections were clinically indicated, and identify variation across socioeconomic groups.MethodsWe conducted a population-based study using routine records of the Live Births Information System in Brazil from January 1, 2011, to December 31, 2017. We calculated the relative size of each Robson group; the caesarean section rate; and the contribution to the overall caesarean section rate. We categorised Brazilian municipalities using the Human Development Index to explore caesarean section rates further. We estimated the time trend in caesarean section rates.ResultsThe rate of caesarean sections was higher in older and more educated women. Prelabour caesarean sections accounted for more than 54 % of all caesarean deliveries. Women with a previous caesarean section (Group 5) made up the largest group (21.7 %). Groups 6–9, for whom caesarean sections would be indicated in most cases, all had caesarean section rates above 82 %, as did Group 5. The caesarean section rates were higher in municipalities with a higher HDI. The general Brazilian caesarean section rate remained stable during the study period.ConclusionsBrazil is a country with one of the world’s highest caesarean section rates. This nationwide population-based study provides the evidence needed to inform efforts to improve the provision of clinically indicated caesarean sections. Our results showed that caesarean section rates were lower among lower socioeconomic groups even when clinically indicated, suggesting sub-optimal access to surgical care.
Highlights
Applying the Robson classification to all births in Brazil, the objectives of our study were to estimate the rates of caesarean section delivery, assess the extent to which caesarean sections were clinically indicated, and identify variation across socioeconomic groups
Live Birth Information System (SINASC) records all registered live births in Brazil using a standardised form that is completed by a health professional who attended the delivery
The Live Births Information System (SINASC) recorded 20,462,786 live births in Brazil between 2011 and 2017, 55.7 % (n = 11,405,901) of which were delivered by caesarean section
Summary
Applying the Robson classification to all births in Brazil, the objectives of our study were to estimate the rates of caesarean section delivery, assess the extent to which caesarean sections were clinically indicated, and identify variation across socioeconomic groups. Identifying an unindicated caesarean section for any given woman or foetus is problematic, not least because financial incentives may encourage health systems and providers to use “soft” indications that are difficult to challenge To address this problem, the Robson classification system has been used to group women into one of ten mutually-exclusive categories, based on six essential obstetric characteristics [5], namely: parity, previous caesarean section, gestational age, the onset of labour, foetal presentation, and number of fetuses [5]. An additional category comprises women who could not be classified because of missing or contradictory information This instrument has been used worldwide to reduce the rates of unnecessary caesarean sections and improve obstetric care, and is indicated by WHO as a monitoring tool [6]
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