Cesarean section rates in Brazil Trend analysis using the Robson classification system

Cesarean section (CS) is a surgical procedure used to deliver babies that is medically indicated to prevent maternal and neonatal mortality. However, it is associated with short- and long-term risks. CS rates have increased, and efforts are being made to ensure that CS is performed only when necessary. The Robson classification system is considered useful for studying, evaluating, monitoring, and comparing CS rates within and between healthcare facilities. In Brazil, there are few studies on this subject, and no large epidemiological studies on this topic utilizing the Robson classification have been reported. This study aimed to report and analyze CS rates in Brazil using the Robson classification system, and subsequently suggest possible measures to address it. Data were collected from the Brazilian Live Birth Information System (Sistema de Informacoes sobre Nascidos Vivos) that contains data of the entire obstetric population, from 2014 to 2017. All births in the country during this period were analyzed according to the Robson classification. A total of 11,774,665 live births were reported in Brazil during 2014 to 2017, most of which were mostly via CS (55.8%). Regions with high human development indexes had significantly higher CS rates than those with low human development indexes. The Robson group (RG) 1 to 4 accounts for 60.2% of live births and 47.1% of all CSs. RG5 was larger than all the other groups and contributed to the highest global rate of CS (31.3%), in addition to being the group who presented the largest growth. Although RG 1 to 4 present favorable initial conditions for vaginal delivery, CS accounted for almost half of births in these groups. The size of RG1 and RG2 in Brazil was comparable to that in countries with low CS rates; however, CS rates in these groups were 3 times higher in Brazil. Nulliparous women in RG1 and RG2 who undergo CS are subsequently categorized into RG5, increasing the global CS rate by 1% annually. We suggest the implementation of health policies to avoid the unnecessary performance of CS in RG1 and RG2 to decrease the CS rates in Brazil.