Cesarean delivery rates in referral service: the Robson classification system in identification and prevention strategies

Abstract

The Hospital das Clínicas da Faculdade de Medicina de Botucatu (HC-FMB/Unesp) is referral service within the State of São Paulo in Brazil. The maternity of HC-FMB/Unesp is a reference to the high obstetric risk in the unified health system (SUS), including a specialized service of Diabetes and Pregnancy stage of teaching, research and assistance in these high-risk pregnancies. Based on indexes of Nations with low maternal and perinatal mortality, the World Health Organization (WHO) recommended, in 1985, that the rate of Cesarean section should not exceed 15%. Since then, these rates have become global goals to be achieved. In Brazil, the percentage of births by c-section in 2011 was 53.88%, corresponding to 59.49% in the Southeast and 60.02% in the State of São Paulo in Brazil. Propose and implement measures to reduce the rates of Cesarean section requires major challenges, in addition to critical study to identify pregnant women most at risk. Robson proposed, in 2001, a simple system of classification of Cesarean section of clinical relevance, reproducible and reliable. In addition, it is the audit and monitoring tool and the one that best meets local needs and international include data commonly registered in institutions of various levels of assistance. This instrument has been used worldwide, in audits and identifying strategies to reduce c-section rates and improve obstetric care. The protocol is based on maternal characteristics, of pregnancy and childbirth, parity, the previous delivery via, kind of pregnancy, early labor (TP) and gestational age, fully inclusive and mutually exclusive features that set the 10 Robson groups. In Brazil, the Robson system has already been used for monitoring obstetric practice in large maternity, with good results. The World Health Organization (who), in its Declaration of 10 April 2015, proposes the classification of Cesarean section of Robson is used as standard instrument to assess, monitor and compare rates of Cesarean section over time on the same or between different hospitals of the same region or country. In this context, the proposal of the study is justified, with the objective to assess, in the maternity ward of the HC-FMB/Unesp, rates and the groups at greatest risk for cesarean section, using the Robson 10-group classification system (RTGCS). From the results, the goal is to propose strategies for the reduction of these rates. a cross-sectional study shall be developed, including all deliveries, vaginal and cesarean section, conducted over the past three years [1/1/2014 to 12/31/2016], in the maternity ward of the HC-FMB/Unesp, reference to the high obstetric risk SUS. The sample is of convenience, including all deliveries, cesarean section and vaginal, conducted over the past three years. Considering the demand of 150 deliveries/month service, would be referred to, in three years, 5400 deliveries; with the index of 40 to 50% of Cesarean section, would be expected a minimum of 2160 cesarean section and vaginal births 3240. The data will be collected, retro and prospectively, delivery records in the electronic data system of the HC-FMB/Unesp. According to the assessment tool, will be identified maternal characteristics, of pregnancy and childbirth and the deliveries will be distributed in the 10 groups of Robson. Comparison tests of proportions shall be used, within each category - vaginal birth and cesarean section, between each of the 10 groups of Robson. The estimated risk for c-section will be performed, defined by the odds ratio, with calculation of odds ratio (OR) and 95% confidence interval (95%). The choice of the respective tests shall be determined by the normal distribution (parametric test) or not (non-parametric) of the results and statistical advice-oriented research support Office (EAP) of the FMB/Unesp. For all statistical tests will be set the limit of significance of 95% (p < 0.05). (AU)