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Using the Robson Classification to Assess Caesarean Section Rates in Brazil: an Observational Study of More Than 24 Million Births from 2011 to 2017 Enny S

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Using the Robson Classification to Assess Caesarean Section Rates in Brazil: an Observational Study of More Than 24 Million Births from 2011 to 2017 Enny S Paixao et al. BMC Pregnancy and Childbirth (2021) 21:589 https://doi.org/10.1186/s12884-021-04060-5 RESEARCH ARTICLE Open Access Using the Robson classification to assess caesarean section rates in Brazil: an observational study of more than 24 million births from 2011 to 2017 Enny S. Paixao1,2*, Christian Bottomley1, Liam Smeeth1, Maria Conceicao N. da Costa2,3, Maria Gloria Teixeira2,3, Maria Yury Ichihara2, Ligia Gabrielli3, Mauricio L. Barreto2 and Oona M. R. Campbell1 Abstract Background: 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. Methods: We 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. Results: The 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. Conclusions: Brazil 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. Keywords: Robson classification, Caesarean section rates, Brazil, Mode of delivery * Correspondence: [email protected] 1Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom 2Centro de Integração de Dados e Conhecimentos para Saúde, Fiocruz, Salvador, Bahia, Brazil Full list of author information is available at the end of the article © The Author(s). 2021 Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Paixao et al. BMC Pregnancy and Childbirth (2021) 21:589 Page 2 of 8 Background pregnancies as a proxy for parity. We also subdivided An ideal rate of caesarean sections has not been agreed, Robson Groups 2 and 4 into 2a and 2b and 4a and 4b to however, the progressive increase in caesarean section distinguish women with induced labour from those with deliveries has intensified debate over the procedure in a pre-labour caesarean section. the last decade [1–3]. Although a caesarean section can We estimated the rate of caesarean section stratified be life-saving, it can also pose unnecessary risks to by maternal age (< 20, 20–24, 25–29, 30–34, 35–39, 40– mothers and babies [4]. In the absence of a clear medical 44, and > 45 years), maternal education (illiterate, 1–3 indication, the benefits of a caesarean section remain years, 4–7 years, 8–11 years and more than 12 years), uncertain. maternal marital status (single, widow, divorced, mar- Identifying an unindicated caesarean section for any ried), gestational age (20–21, 22–23, 24–25, 26–27, 28– given woman or foetus is problematic, not least because 29, 30–31, 32–33, 34–35, 36–37, 38–39, 40–41, > 42 financial incentives may encourage health systems and weeks), birth weight (< 1,500, 1500–1999, 2000–2499, providers to use “soft” indications that are difficult to 2500–2999, 3000–3499, 3500–3999, > 4000 g), number challenge. To address this problem, the Robson classifi- of foetuses, delivery presentation, onset of labour, previ- cation system has been used to group women into one ous gestations and previous caesarean sections. of ten mutually-exclusive categories, based on six essen- As recommended by WHO [13], we calculated the tial obstetric characteristics [5], namely: parity, previous proportion of deliveries in each Robson group, the pro- caesarean section, gestational age, the onset of labour, portion of deliveries in each group that were by caesar- foetal presentation, and number of fetuses [5]. An add- ean section, and the contribution of each group to the itional category comprises women who could not be overall caesarean section rate (number of caesarean de- classified because of missing or contradictory informa- liveries divided by the total number of births). tion. This instrument has been used worldwide to re- To further explore caesarean section rates within each duce the rates of unnecessary caesarean sections and Robson Group, we categorised Brazilian municipalities improve obstetric care, and is indicated by WHO as a as having a very high, high, medium, or low Human De- monitoring tool [6]. velopment Index (HDI), based on the 2010 Human De- In Brazil, the Robson classification system has been velopment Report [14], and estimated caesarean section previously applied in the national “Birth in Brazil” cohort rates stratified by HDI category. [7], and some hospital-based studies in Sao Paulo [8] Finally, we estimated the time trend (β coefficient and Brasilia [9]. Using routinely collected birth registra- which corresponds to the change in the caesarean sec- tion data, the objectives of our study were to (1) estimate tion rate for every year) in caesarean section rates for the caesarean rate in Brazil stratified by Robson cat- each Robson group using either simple linear regression egory, (2) assess the extent to which caesarean sections or the Prais-Winsten method if there was evidence of were clinically indicated, and (3) identify any variation autocorrelation (Durbin-Watson statistic > 2) [15]. across different socioeconomic groups. Methods Results We conducted a population-based study using routine The Live Births Information System (SINASC) recorded records of the Live Births Information System (Sistema 20,462,786 live births in Brazil between 2011 and 2017, de Informação sobre Nascimentos; SINASC) in Brazil 55.7 % (n = 11,405,901) of which were delivered by cae- from January 1, 2011 to December 31, 2017. SINASC re- sarean section. The characteristics of these births are cords all registered live births in Brazil using a standar- shown in Table 1. The rate of caesarean sections was dised form that is completed by a health professional higher in older and more educated women, and in- who attended the delivery. The Brazilian Ministry of creased with gestational age with a peak at 36–39 weeks Health maintains the data, and an evaluation of the birth (60 %). Prelabour caesarean sections accounted for more registration system found that over 97 % of Brazilian live than 54 % of all caesarean deliveries. births were registered [10]. The form includes informa- A total of 15,426,356 (75.4 %) records had information tion on the mother (name, place of residence, age, mari- on all six core variables required for the Robson classifi- tal status, education); the pregnancy (length of gestation, cation. Women with a previous caesarean section was mode of delivery); and the neonate (birth weight, pres- the largest group (Group 5, 21.7 %), followed by primi- ence of congenital anomalies) [11]. In 2011, the form gravidae women with a single cephalic pregnancy at was amended to include information about the father, 37 + weeks gestation in spontaneous labour (Group 1, birth conditions, and obstetric history [12]. 16.1 %) and primigravidae women who had labour in- Because the SINASC form does not have information duced or had a prelabour caesarean section (Group 2, on previous births, we used the number of previous 17.2 %) (Table 2). Paixao et al. BMC Pregnancy and Childbirth (2021) 21:589 Page 3 of 8 Table. 1 Characteristics of 20,462,786 live births in Brazil from 2011–2017 by mode of delivery Characteristics Vaginal Births Caesarean section births Total births Caesarean section rate (%) Age of the mother < 20 years 2,257,865 1,507,565 3,765,430 40.0 20–24 2,651,696 2,561,203 5,212,899 49.1 25–29 2,029,296 2,934,567 4,963,863 59.1 30–34 1,334,853
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