Cesarean section rates according to the Robson Classification and its association with adequacy levels of prenatal care: a cross-sectional hospital-based study in Brazil

Abstract

Background The rate of Cesarean section (CS) deliveries has been increasing worldwide for decades. Brazil exhibits high rates of patient-requested CS deliveries. Prenatal care is essential for reducing and preventing maternal and child morbidity and mortality, ensuring women's health and well-being. The aim of this study was to verify the association between the level of prenatal care, as measured by the Kotelchuck (APNCU – Adequacy of the prenatal care utilization) index and CS rates. Methods We conducted a cross-sectional study based on data from routine hospital digital records and federal public health system databases (2014–2017). We performed descriptive analyses, prepared Robson Classification Report tables, and estimated the CS rate for the relevant Robson groups across distinct levels of prenatal care. Our analysis also considered the payment source for each childbirth – either public healthcare or private health insurers – and maternal sociodemographic data. Results CS rate by level of access to prenatal care was 80.0% for no care, 45.2% for inadequate, 44.2% for intermediate, 43.0% for adequate, and 50.5% for the adequate plus category. No statistically significant associations were found between the adequacy of prenatal care and the rate of cesarean sections in any of the most relevant Robson groups, across both public (n = 7,359) and private healthcare (n = 1,551) deliveries. Conclusion Access to prenatal care, according to the trimester in which prenatal care was initiated and the number of prenatal visits, was not associated with the cesarean section rate, suggesting that factors that assess the quality of prenatal care, not simply adequacy of access, should be investigated.

Trends in cesarean section rates in Brazil by Robson classification group, 2014-2020

“…Additionally, other Brazilian studies using the Robson Classification were localized ( 21 - 22 ) , restricted to specific institutions ( 23 - 24 ) , or had different objectives, such as evaluating the association between cesareans and prematurity ( 25 ) or the association between access to prenatal care and the occurrence of cesareans ( 26 ) . Other studies employed the Robson Classification to assess the occurrence of cesareans in the country but during periods close to its implementation as a strategy, such as from 2011 to 2017 ( 20 ) , and from 2014 to 2016 ( 27 ) .…”

“…Ainda, outros estudos brasileiros que utilizaram a classificação de Robson foram locais ( 21 - 22 ) , restritos a instituições ( 23 - 24 ) , ou tiveram outros objetivos como avaliar a associação entre cesarianas e prematuridade ( 25 ) ou a associação entre acesso ao pré-natal e ocorrência de cesáreas ( 26 ) . Outros estudos utilizaram a classificação de Robson para avaliar a ocorrência de cesáreas no país, mas em períodos anteriores, muito próximos da sua implementação enquanto estratégia, tais como de 2011 a 2017 ( 20 ) , e de 2014 a 2016 ( 27 ) .…”