title: Use of Robson classification to assess cesarean section rate in Brazil: the role of source of payment for childbirth.
abstract: BACKGROUND
  Cesarean section (CS) rates are increasing worldwide but there is some concern with this trend because of potential maternal and perinatal risks. The Robson classification is the standard method to monitor and compare CS rates. Our objective was to analyze CS rates in Brazil according to source of payment for childbirth (public or private) using the Robson classification.
  
  
  METHODS
  Data are from the 2011-2012 "Birth in Brazil" study, which used a national hospital-based sample of 23,940 women. We categorized all women into Robson groups and reported the relative size of each Robson group, the CS rate in each group and the absolute and relative contributions made by each to the overall CS rate. Differences were analyzed through chi-square and Z-test with a significance level of < 0.05.
  
  
  RESULTS
  The overall CS rate in Brazil was 51.9 % (42.9 % in the public and 87.9 % in the private health sector). The Robson groups with the highest impact on Brazil's CS rate in both public and private sectors were group 2 (nulliparous, term, cephalic with induced or cesarean delivery before labor), group 5 (multiparous, term, cephalic presentation and previous cesarean section) and group 10 (cephalic preterm pregnancies), which accounted for more than 70 % of CS carried out in the country. High-risk women had significantly greater CS rates compared with low-risk women in almost all Robson groups in the public sector only.
  
  
  CONCLUSIONS
  Public policies should be directed at reducing CS in nulliparous women, particularly by reducing the number of elective CS in these women, and encouraging vaginal birth after cesarean to reduce repeat CS in multiparous women.
authors: National Institute of Women, Children and Adolescents Health Fernandes Figueira, Oswaldo Cruz Foundation, Avenida Rui Barbosa 716 - Flamengo, CEP 22.250-020, Rio de Janeiro, RJ, Brazil. marcosnakamura@globo.com.|National School of Public Health - Oswaldo Cruz Foundation, Rua Leopoldo Bulhões, 1480, sala 809, Manguinhos, Rio de Janeiro, CEP 21041-210, Brazil. marcosnakamura@globo.com.
authors: Marcos
authors: M
authors: Nakamura-Pereira
authors: National School of Public Health - Oswaldo Cruz Foundation, Rua Leopoldo Bulhões, 1480, sala 809, Manguinhos, Rio de Janeiro, CEP 21041-210, Brazil.
authors: Maria
authors: M
authors: do Carmo Leal
authors: National School of Public Health - Oswaldo Cruz Foundation, Rua Leopoldo Bulhões, 1480, sala 809, Manguinhos, Rio de Janeiro, CEP 21041-210, Brazil.
authors: Ana Paula
authors: AP
authors: Esteves-Pereira
authors: National Institute of Infectology, Oswaldo Cruz Foundation, Avenida Brasil 4.365 - Manguinhos, Rio de Janeiro, RJ, CEP 21.040-900, Brazil.
authors: Rosa Maria Soares Madeira
authors: RM
authors: Domingues
authors: National Health Agency - Ministry of Health, Av. Augusto Severo, 84 - Glória, Rio de Janeiro, RJ, 20021-040, Brazil.
authors: Jacqueline Alves
authors: JA
authors: Torres
authors: National Institute of Women, Children and Adolescents Health Fernandes Figueira, Oswaldo Cruz Foundation, Avenida Rui Barbosa 716 - Flamengo, CEP 22.250-020, Rio de Janeiro, RJ, Brazil.
authors: Marcos Augusto Bastos
authors: MA
authors: Dias
authors: National Institute of Women, Children and Adolescents Health Fernandes Figueira, Oswaldo Cruz Foundation, Avenida Rui Barbosa 716 - Flamengo, CEP 22.250-020, Rio de Janeiro, RJ, Brazil.
authors: Maria Elisabeth
authors: ME
authors: Moreira
mesh_terms: D000293:Adolescent; D000328:Adult; D001723:Birth Rate; D001938:Brazil; D002585:Cesarean Section / Q000145:classification / Q000191:economics* / Q000706:statistics & numerical data*; D002648:Child; D005260:Female; D006801:Humans; D007231:Infant, Newborn; D007348:Insurance, Health / Q000706:statistics & numerical data*; D036801:Parturition; D011247:Pregnancy; D055815:Young Adult
keywords: Brazil; Cesarean section; Health systems; Robson classification