| |

Received: 21 February 2020    Revised: 17 June 2020    Accepted: 4 September 2020

DOI: 10.1002/ijgo.13370

CLINICAL ARTICLE
Obstetrics

Can pre‐eclampsia explain higher cesarean rates in the

different groups of Robson's classification?

Mariana P. Sanchez | Jose P. Guida* | Marcela Simões | Marcos Marangoni‐Junior | 

Christopher Cralcev | Juliana C. Santos | Tabata Z. Dias | Adriana G. Luz | 
Maria L. Costa

Departament of Obstetrics and

Gynecology, University of Campinas,
Campinas, São Paulo, Brazil
*Correspondence
José P. Guida, Department of Obstetrics
and Gynecology, University of Campinas,
Campinas, Brazil.
Email: zepauloguida@gmail.com
Abstract
Objective: To evaluate the impact of pre‐eclampsia on cesarean delivery by using the
Robson classification.
Methods: A retrospective cross‐sectional study including all women who delivered in
a referral maternity hospital in southeast Brazil from January 2017 to February 2018.
Women were classified into 1 of 10 Robson groups and then further subdivided into
pre‐eclampsia (PE) and non‐PE (NPE) groups. Frequency of cesarean was determined
for each group and compared by using χ2 and prevalence ratio.
Results: Overall, 3102 women were included, of whom 1578 (50.9%) delivered by
cesarean. Classification in Robson group 5 was the most frequent among all women
(n=727, 23.4%). In the PE group (n=258, 8.3%), group 10 was the most frequent classifi‐
cation (n=120, 46.5%); in NPE, Robson group 5 was the most frequency (n=682, 24.0%).
Pre‐eclampsia was associated with a higher occurrence of cesarean (77.5% vs 48.4%;
prevalence ratio, 2.29; 95% confidence interval, 1.82–2.82), owing to higher rates in
Robson groups 1, 5, and 10.
Conclusion: Pre‐eclampsia was associated with a higher occurrence of cesarean deliv‐
ery in some Robson groups. Robson classification may be used to evaluate the impact
of specific conditions at a facility level to help plan future interventions to optimize the
use of cesarean.

KEYWORDS
Audit; Birth; Cesarean rates; Delivery; Pre‐eclampsia; Robson classification

1 |  INTRODUCTION
Pre‐eclampsia is an important cause of severe maternal morbidity,
maternal death, and prematurity worldwide. In middle and low‐income
countries, hypertensive disorders in pregnancy are the main cause of
complications during the reproductive cycle.1–4 Pre‐eclampsia is diag‐
nosed when there is new onset of hypertension (systolic blood pres‐
sure ≥140 mm Hg or diastolic blood pressure ≥90 mm Hg), associated
with proteinuria or other laboratory or clinical findings of organ dam‐
age, after 20 gestational weeks.5–7 Pre‐eclampsia is not an indication
for cesarean deliveries; however, it is associated with higher rates of
this type of delivery.8
Cesarean rates may reflect the quality of obstetric care. However,
the adequate threshold for cesarean remains controversial. In 1985,
the WHO stated that cesarean rates higher than 10%–15% were not
justifiable by any medical reason in any world region9; however, that
statement was not supported by scientific evidence but was based
on specialist consensus. Recently, in response to increased rates of
cesarean deliveries worldwide and to support future recommenda‐
tions, WHO conducted a systematic review10 and further declared

Int. J. Gynecol. Obstet. 2020; 1–6 © 2020 International Federation of |  1

wileyonlinelibrary.com/journal/ijgo  
Gynecology and Obstetrics
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2       Sanchez ET AL.
that cesarean delivery does save maternal and neonatal lives, but rates
higher than 15% do not improve maternal, fetal, or perinatal outcomes
in low‐risk populations.11
Several systems to understand the magnitude of the increase in
rates of cesarean have been suggested. Robson proposed a 10‐group
classification, in which every woman is categorized into 1 of 10 groups.
The 10 groups are mutually exclusive and totally inclusive, and use of
the classification is easy and dynamic.12,13 Robson classification facil‐
itates comparisons among different regions and facilities, and even
between different timepoints within the same facility. It considers
parity, number of fetuses, fetal presentation, previous cesarean deliv‐
ery, gestational age, and onset of labor; however, it does not consider
maternal or fetal morbidities, intrapartum complications, or indica‐
tions for cesarean. Furthermore, maternal and perinatal outcomes are
not evaluated by this system.
The WHO formally endorsed Robson classification in 2014 as a
global system for assessing, monitoring, and comparing cesarean rates
among facilities, countries, and regions.11 To our knowledge, only a
few studies have applied Robson classification to women with spe‐
cific conditions.14,15 The aim of the present study was to understand
the impact of pre‐eclampsia on cesarean delivery rates among women
categorized by the 10 groups of Robson classification.
2 |  MATERIALS AND METHODS
The present retrospective cross‐sectional study assessed data from all
women who delivered at the Women’s Hospital at the University of
Campinas, São Paulo, Brazil, between January 1, 2017, and February
28, 2018. The research protocol was approved prior to data collec‐
tion by the local ethics review board (#19450013900005404) and
informed consent was waived owing to the retrospective study design.
The study maternity hospital, an academic and training unit within
the University of Campinas, is a public tertiary hospital in southeast
Brazil that provides care for women with low‐ and high‐risk pregnan‐
cies, covering a population of 1  000  000 individuals. It has approxi‐
mately 2500 low‐ and high‐risk births annually (half of all deliveries
are considered high risk), providing specialized prenatal and delivery
care for women with hypertension, cardiac disease, diabetes, and fetal
malformations, among other disorders.
Data for the present study was obtained by medical chart review.
The following variables were retrieved: maternal age, parity, gesta‐
tional age, number of fetuses, fetal presentation, onset of labor, blood
pressure, diagnosis of pre‐eclampsia, presence of proteinuria, and
presence of renal, hepatic, hematologic, pulmonary, neurologic, or
cardiac disorders.
The diagnostic criteria considered in the facility for pre‐eclampsia
were hypertension coupled with significant proteinuria or presence
of organic damage. Hypertension was defined as the occurrence of
two or more measures of systolic blood pressure higher or equal to
140 mm Hg or diastolic blood pressure higher or equal to 90 mm Hg.
Significant proteinuria was considered when a 24‐hour protein mea‐
surement was higher or equal to 300 mg. Organic damage was defined
BOX 1. Robson classification and characteristics of
women included in each group.a
Group Characteristics
1 Nulliparous, single cephalic, ≥37 wk, in spontane‐
ous labor
2 Nulliparous, single cephalic, ≥37 wk, induced or
cesarean before labor
3 Multiparous (excluding previous cesarean), single
cephalic, ≥37 wk, in spontaneous labor
4 Multiparous (excluding previous cesarean), single
cephalic, ≥37 wk, induced or cesarean before
labor
5 Previous cesarean, single cephalic, ≥37 wk
6 All nulliparous breeches
7 All multiparous breeches, including previous
cesarean
8 All multiple pregnancies, including previous
cesarean
9 All abnormal lies, including previous cesarean
10 All single cephalic, <37 wk, including previous
cesarean
a
Based on Ref.11
as laboratory or clinical evidence of organic disorders (e.g., creatinine,
≥1.2  mg/dL; transaminase, ≥70  U/L [or twice the reference]; lactate
dehydrogenase, ≥600 mg/dL; platelets, ≤100 000/dL; headache, sco‐
tomas, or upper‐right abdominal pain).
The study was observational and therefore no formal sample size
calculation was conducted. To estimate the minimum numbers of
women expected in each Robson group at a 99% confidence level,
we considered a previous study conducted in a Brazilian facility with
a similar number of deliveries.16 Based on that study, the number of
women expected in each Robson group was group 1, 457; group 2,
200; group 3, 374; group 4, 135; group 5, 350; group 6, 46; group 7,
36; group 8, 41; group 9, 8; group 10, 213.
Data were stored in Excel 2013 (Microsoft, Redmond, WA, USA)
and processed with EpiInfo 7.2 (CDC, Atlanta, GA, USA). Each woman
was classified into 1 of the 10 Robson groups (Box 1) and women were
further divided into pre‐eclampsia (PE) and non‐pre‐eclampsia (NPE)
groups. The number of women and frequency of cesarean section in
each Robson’s group was obtained, and the occurrence of pre‐eclamp‐
sia in each group was determined. Cesarean rates in each Robson group
were compared between the PE and NPE groups by χ2 test, and the
prevalence ratio and respective confidence intervals (CIs) were calcu‐
lated. A P value of less than 0.05 was considered statistically significant.
3 | RESULTS
In total, there were 3102 deliveries during the study period that were
included in the analysis. Overall, the mean age of the study women
Sanchez ET AL.
was 28.7 ± 6.8 years and 1130 (36.4%) women were nulliparous. The
mean gestational age at delivery was 38.7 ± 1.7 weeks and diabetes
was the most frequent comorbidity (n=448, 14.4%). Table 1 summa‐
rizes the sociodemographic, obstetric, and clinical characteristics of
the study women.
Group 5 (women with previous cesarean, single cephalic fetus,
and gestational age ≥37 weeks) was the largest Robson group (n=727,
23.4%), followed by group 1 (nulliparous, single cephalic, ≥37 weeks,
in spontaneous labor; n=614, 19.8%), group 3 (multiparous, single
cephalic, ≥37  weeks, in spontaneous labor; n=576, 18.6%), group
10 (single cephalic, <37  weeks, including previous cesarean; n=452,
14.6%), group 2 (nulliparous, single cephalic, ≥37 weeks, induced or
cesarean before labor; n=292, 9.4%), and group 4 (multiparous, single
cephalic, ≥37 weeks, induced or cesarean before labor; n=230, 7.4%)
(Table 2). Groups 6–9 collectively contributed a small number of cases
(n=211, 6.8%).
Of the 3102 study women, 1578 (50.9%) delivered by cesarean.
Excluding groups 6–9 (which had a small impact on the total number
of cases and had expected high cesarean rates), group 5 had the high‐
est cesarean rate (72.3%) and group 3 had the lowest cesarean rate
(25.5%). Group 5 was also the responsible for the majority of cesarean
deliveries performed (33.3%), followed by group 10 (17.7%) and group
1 (14.4%) (Table 2).
Overall, 258 (8.3%) of the 3102 study women had pre‐eclampsia,
of whom 137 (4.4%) were affected before 37 gestational weeks. In the
NPE group (n=2844), Robson group 5 was the most frequent, followed
by groups 1 and 3; in the PE group, by contrast, Robson group 10 was
the most frequent, followed by groups 5 and 2. Overall, 120 (46.5%)
women with pre‐eclampsia were in group 10, as compared with 332
(11.7%) women without pre‐eclampsia (Table 3).
The rate of cesarean in each Robson classification was compared
between the PE and NPE groups (Table 4). In total, 200 (77.5%) women
delivered by cesarean in the PE groups, as compared with 1378 (48.4%)
women in the NPE group (prevalence ratio, 2.29; 95% CI, 1.82–2.88;
P < 0.001). This difference was mainly due to the higher occurrence of
cesarean in groups 1, 5, and 10. Women with pre‐eclampsia were 2.57
T A B L E 1   Sociodemographic, obstetric, and clinical characteristics
of all study women.a
Value
Characteristic (n=3102)
Age, y 28.66 ± 6.75
Primigravida 1130 (36.4)
Gestational age, wk 38.66 ± 1.68
b ever, even those groups have high rates of cesarean delivery. Reducing
Diabetes   448 (14.4)
Chronic hypertension 167 (5.4)
Mode of delivery
Cesarean 1578 (50.9)
Vaginal 1526 (49.1)
Analgesia for vaginal delivery 791 (51.9)
a
Values are given as mean ± SD or number (percentage).
b
Including gestational, type 1, and type 2 diabetes.
|
      3
(95% CI, 1.20–5.50) times more likely to undergo a cesarean delivery
in Robson group 1, and 2.46 (95% CI, 1.65–3.66) times more likely
in group 10. The occurrence of cesarean was also higher in Robson
group 5 for women with pre‐eclampsia (P=0.026). Group 2 was the
third most frequent Robson group among women with pre‐eclampsia,
and the rate of cesarean in this group was high (59.3%), importantly
contributing to the overall cesarean rate in the PE group.
4 | DISCUSSION
The present study evaluated the distribution of deliveries in a tertiary
maternity hospital over 13 months by Robson classification. It also con‐
sidered the occurrence of pre‐eclampsia and the association between
pre‐eclampsia and cesarean rates among these women. The results
demonstrate that there was an overall high cesarean rate, and pre‐
eclampsia was associated with a further increase in cesarean delivery.
Brazil has one of the highest rates of cesarean delivery worldwide.
Despite national and local17 efforts to reduce cesarean delivery and
improve obstetric care, including the implementation of national pro‐
grams centered not only on obtaining good perinatal outcomes, but
also on allowing women to have a positive experience during deliv‐
ery,18 the incidence of cesarean delivery is increasing in line with the
global trend.19 The present study found a cesarean rate (50.9%) higher
than that reported by another recent multicenter Brazilian study
(39%).14 Many factors are associated with the rise in Brazilian cesarean
rates, such as quality of prenatal care, assistance during childbirth, role
of payment sources, women’s cultural believes, empowerment and
autonomy, and even medicolegal issues.15
The present distribution of women in Robson groups was similar
to that observed in a national survey conducted in 2010 that included
women with severe maternal morbidity19; however, the present fre‐
quency of women in group 10 was higher. In contrast to the “Born in
Brazil” study,19 a multicenter study including both referral and regular
care facilities, the present study included data from only one tertiary
center; thus, the higher frequency of preterm deliveries is likely to
be related to the greater complexity of cases admitted for childbirth.
When comparing rates of cesarean delivery among Robson groups to
the previous national survey,19 the present rates were lower in groups
2 and 4, similar in group 5, and higher in group 10.
Robson groups 1–4 (nulliparous or multiparous women without
previous cesarean) should have considered obstetric management,
because they are at low risk for cesarean delivery (expected frequency
of 10.0%, 35.0%, 3.0%, and 15.0%, respectively).20 In Brazil,19 how‐
the incidence of cesarean in those groups will be key to long‐term
reduction of the overall rate of cesarean delivery in Brazil, because
having a previous cesarean is the main risk factor for cesarean deliv‐
ery.21 Avoiding a first cesarean will be more effective than convincing
a woman to undergo a trial of labor after cesarean.
Whereas other systems consider indications for performing a
cesarean, leading to disarray and unstandardized parameters, Robson
classification considers inclusive and mutually exclusive individual
 |
4       Sanchez ET AL.

T A B L E 2   Distribution of the study women by Robson group and cesarean delivery.

No. (%) of cesareans in Contribution of Robson group

Robson group Total no. (%) of women Robson group to overall cesarean rate, %

1 614 (19.8) 227 (37.0) 14.4

2 292 (9.4) 138 (47.3) 8.7
3 576 (18.6) 147 (25.5) 9.3
4 230 (7.4) 78 (33.9) 4.9
5 727 (23.4) 526 (72.3) 33.3
6 57 (1.8) 49 (86.0) 3.1
7 112 (3.6) 94 (84.0) 6.0
8 31 (1.0) 28 (90.3) 1.8
9 11 (0.3) 11 (100) 0.7
10 452 (14.6) 280 (61.9) 17.7
Total 3102 1578 (50.9) 100.0

characteristics, allowing a unique classification of each woman to a
pre‐specified group. Its intuitive design and ease of implementation
are other strengths of the classification. However, the lack of consen‐
sus about some variables is a problem: for instance, defining when
labor starts may vary in different settings and may lead to misclassifi‐
cation among groups 1 to 4. In addition, data collected in routine care
may be not accurate, even in high‐resource countries, and women may
22
not be adequately classified.
Another point of concern regarding Robson classification is the
fact that it completely ignores maternal morbidities, a condition that,
as the present results have shown, may interfere with cesarean rates.
This has also been demonstrated in the C‐model, a proposal that uses
Robson classification and adds other relevant information, including
underlying medical conditions and obstetric complications, to better
predict the rate of cesarean for specific cases.23
T A B L E 3   Distribution of the study women by Robson group and
occurrence of pre‐eclampsia.a
NPE group
Robson group PE group (n=258) (n=2844)
1 20 (7.7) 594 (21.0)
2 27 (10.5) 265 (9.3)
3 10 (3.9) 566 (19.9)
4 14 (5.4) 216 (7.6)
5 45 (17.4) 682 (24.0)
6 7 (2.7) 50 (1.8)
7 14 (5.4) 98 (3.4)
8 1 (0.4) 30 (1.0)
9 0 (0) 11 (0.4)
10 120 (46.5) 332 (11.7)
Helping to understand the characteristics of a facility (or even
a region) and comparing a facility, either with itself over time or
with other facilities, are the main strengths of Robson classification.
Its flexibility, reproducibility, robustness, and simplicity have been
recognized as its main advantages, whereas its lack of explanations
about the reasons to perform a cesarean are its main drawbacks.22 A
study to evaluate the implementation of Robson classification as an
intervention to reduce cesarean rates would be relevant and would
provide evidence about the expected cesarean rate for women
included in each group.22
The prevalence of pre‐eclampsia in Brazil is estimated as 1.2%–
4.2%,24 although this number might be underestimated. The pres‐
ent study found a frequency of pre‐eclampsia of 8.3%, and almost
half of the cases occurred before 37 gestational weeks. This high
number is justified by the referral of the most severe cases in the
region to the study institution. In the study facility, as previously
reported,25 induction of labor is considered for pregnant women
from a gestational age of 32 weeks onward. This recommendation
may partially explain the high rates of cesarean in group 10; how‐
ever, the number of cases included in group 10 in the present anal‐
ysis is too small to support any conclusion. Continuous surveillance
should focus on preterm deliveries and possibly consider an analysis
of subgroups according to gestational age, with targeted interven‐
tions in late preterm, in order to increase induction of labor and
reduce the rate of cesarean.
Among women with pre‐eclampsia that presents after 34 weeks
(late‐preterm pre‐eclampsia), the optimal timing for delivery is unclear,
and the risks of maternal disease progression need to be considered
against the risks of neonatal complications and prematurity. There is
strong evidence to suggest that a planned delivery can reduce mater‐
nal morbidity, although it leads to more neonatal intensive care unit
admissions due to prematurity; however, increased cesarean section

Total 258 (100) 2844 (100) rates do not decrease neonatal morbidity rates.26
The present study has several limitations. The retrospective study
Abbreviations: NPE, non‐pre‐eclampsia; PE, pre‐eclampsia.
a
Values are given as number (percentage of total number in PE or NPE
design may hinder the accuracy of information obtained and, as a
group). result, some women may have been misclassified in Robson groups.
Sanchez ET AL. |
      5

T A B L E 4   Frequency of cesarean by Robson group and occurrence of pre‐eclampsia.a

No. (%) of cesareans

Robson group PE group NPE group Unadjusted PR (95% CI) P valuea 

1 15 (75.0) 212 (35.7) <0.001 2.57 (1.20–5.50)

2 16 (59.3) 122 (46.0) 0.189 1.32 (0.82–1.10)
3 5 (50.0) 142 (25.1) 0.073 1.49 (0.80–2.78)
4 7 (50.0) 71 (32.9) 0.189 1.34 (0.80–2.28)
5 39 (86.7) 487 (71.4) 0.026 2.14 (1.00–4.55)
6 5 (71.4) 44 (88.0) 0.237 0.42 (0.10–1.68)
7 14 (100) 80 (81.6) 0.080 NA
8 1 (100) 27 (90.0) 0.073 NA
9 0 (0) 11 (100) NA NA
10 98 (81.7) 182 (54.8) <0.001 2.46 (1.65–3.66)
Total 200 (77.5) 1378 (48.4) <0.001 2.29 (1.82–2.88)

Abbreviations: CI, confidence interval; NA, not applicable; NPE, non‐pre‐eclampsia; PE, pre‐eclampsia group; PR, prevalence ratio.
a
By χ2 test.

Due to the study design, only associations were observed from the
results, and cause and effect was not evaluated. In addition, the study
included a relatively small number of deliveries from a single facility
over approximately 1  year; except for group 8, however, all groups
reached the minimum frequency expected by sample size calculation.
Another important point is that the facility where the study was
conducted is a high‐complexity maternity hospital linked to a univer‐
sity. Women who deliver in the hospital tend to have more severe
forms of hypertension or pre‐eclampsia in comparison to those who
deliver in the community or low‐risk settings. The facility is also a train‐
ing unit, and decisions about timing and mode of delivery are shared
by a team of specialists. These characteristics will have influenced the
results and may interfere with the external validity of the findings.
Nevertheless, to the best of our knowledge, the present study is
the first to evaluate the impact of one specific condition (pre‐eclamp‐
sia) on the Robson classification and on cesarean delivery in the 10
Robson groups. The same methodology can be applied to other dis‐
eases or conditions, and even to evaluate the impact of interventions
among women with those conditions.
We note that there are interventions that might increase vaginal
delivery rates, including non‐pharmacologic methods of pain relief;
availability of analgesia for all women, which is safe even for women
with severe maternal morbidity27; and health education, mainly for
women with only one previous cesarean delivery, to clarify the short‐
and long‐term consequences of repeated cesarean procedures.
In summary, the rate of cesarean delivery in a referral mater‐
nity hospital was found to be higher than 50%. The frequency of
pre‐eclampsia was 8.3%, and most women with pre‐eclampsia were
included in Robson group 10. Pre‐eclampsia was significantly associ‐
ated with cesarean delivery, mainly for women classified in Robson
groups 1, 5, and 10. Robson classification might be used in future
studies to evaluate the impact of specific conditions at a facility level,
and to help plan future interventions and reduce the prevalence of
cesarean delivery.
AU T HO R CO NT R I B U T I O NS
MPS contributed to data collection and writing the manuscript. MS,
MM, CC, and JC contributed to data collection and revising the manu‐
script. TZD and AGL contributed to study conception and design, data
interpretation, and revising the manuscript. JPG and MLC contributed
to study conception and design, statistical analysis, data interpreta‐
tion, and writing and reviewing the manuscript.
CO NFL I C TS O F I NT ER ES TS
The authors have no conflicts of interest.
REFERENCES
1. Giordano JC, Parpinelli MA, Cecatti JG, et al. The burden of eclampsia:
Results from a multicenter study on surveillance of severe maternal
morbidity in Brazil. PLoS One. 2014;9:e97401.
2. Souza RT, Cecatti JG, Passini R, et al. The burden of provider‐ini‐
tiated preterm birth and associated factors: Evidence from the
Brazilian Multicenter Study on Preterm Birth (EMIP). PLoS One.
2016;11:e0148244.
3. Leal MD, Esteves‐Pereira AP, Nakamura‐Pereira M, et al. Prevalence
and risk factors related to preterm birth in Brazil. Reprod Health.
2016;13(Suppl.3):127.
4. Delorme P, Goffinet F, Ancel PY, et al. Cause of preterm birth as a
prognostic factor for mortality. Obstet Gynecol. 2016;127:40–48.
5. Gynecologists ACoOa. Pregnancy TFoHi: Hypertension in pregnancy.
Report of the American College of Obstetricians and Gynecologists’
Task Force on Hypertension in Pregnancy. Obstet Gynecol.
2013;122:1122–1131.
6. Steegers EA, von Dadelszen P, Duvekot JJ, Pijnenborg R. Pre‐eclamp‐
sia. Lancet. 2010;376:631–644.
7. Chaiworapongsa T, Chaemsaithong P, Yeo L, Romero R. Pre‐eclampsia
part 1: Current understanding of its pathophysiology. Nat Rev Nephrol.
2014;10:466–480.
8. Guida JP, Parpinelli MA, Surita FG, Costa ML. The impact of protein‐
uria on maternal and perinatal outcomes among women with pre‐
eclampsia. Int J Gynaecol Obstet. 2018;143:101–107.
 |
6       Sanchez ET AL.
9. Appropriate technology for birth. Lancet. 1985;2:436–437.
10. Betran AP, Torloni MR, Zhang J, et al. What is the optimal rate of cae‐
sarean section at population level? A systematic review of ecologic
studies. Reprod Health. 2015;12:57.
11. Betran AP, Torloni MR, Zhang JJ, Gülmezoglu AM. Section
WWGoC: WHO Statement on caesarean section rates. BJOG.
2016;123:667–670.
12. Robson MS. Can we reduce the caesarean section rate? Best Pract Res
Clin Obstet Gynaecol. 2001;15:179–194.
13. Robson M, Hartigan L, Murphy M. Methods of achieving and main‐
taining an appropriate caesarean section rate. Best Pract Res Clin
Obstet Gynaecol. 2013;27:297–308.
14. Dias MA, Domingues RM, Schilithz AO, Nakamura‐Pereira M, do
Carmo Leal M. Factors associated with cesarean delivery during labor
in primiparous women assisted in the Brazilian Public Health System:
data from a National Survey. Reprod Health. 2016;13(Suppl.3):114.
15. Barros FC, Matijasevich A, Maranhão AG, et al. Cesarean sections
in Brazil: Will they ever stop increasing? Rev Panam Salud Publica.
2015;38:217–225.
16. Bolognani CV, Reis LBSM, Dias A, Calderon IMP. Robson 10‐groups
classification system to access C‐section in two public hospitals of the
Federal District/Brazil. PLoS One. 2018;13:e0192997.
17. Haddad SM, Cecatti JG. Strategies directed to professionals for reduc‐
ing unnecessary cesarean sections in Brazil. Rev Bras Ginecol Obstet.
2011;33:252–262.
18. Fernandes RZ, Vilela MF. Strategies for integration of health care
practices and sanitary surveillance in the context of the implemen‐
tation of Rede Cegonha – a Brazilian mother and infant health care
network. Cien Saude Colet. 2014;19:4457–4466.
19. Nakamura‐Pereira M, do Carmo Leal M, Esteves‐Pereira AP, et
al. Use of Robson classification to assess cesarean section rate in
Brazil: the role of source of payment for childbirth. Reprod Health.
2016;13(Suppl.3):128.
20. Robson Classification: Implementation Manual. Geneva. 2017.
21. Guida JP, Pacagnella RC, Costa ML, Ferreira EC, Cecatti JG. Evaluating
vaginal‐delivery rates after previous cesarean delivery using the
Robson 10‐group classification system at a tertiary center in Brazil.
Int J Gynaecol Obstet. 2017;136:354–355.
22. Betrán AP, Vindevoghel N, Souza JP, Gülmezoglu AM, Torloni MR.
A systematic review of the Robson classification for caesarean sec‐
tion: what works, doesn't work and how to improve it. PLoS One.
2014;9:e97769.
23. Souza JP, Betran AP, Dumont A, et al. A global reference for caesarean
section rates (C‐Model): A multicountry cross‐sectional study. BJOG.
2016;123:427–436.
24. Peraçoli JC, Borges VTM, Ramos JGL, et al. Pre‐eclampsia/Eclampsia.
Rev Bras Ginecol Obstet. 2019;41:318–332.
25. Guida JPS, Surita FG, Parpinelli MA, Costa ML. Preterm preeclampsia
and timing of delivery: A systematic literature review. Rev Bras Ginecol
Obstet. 2017;39:622–631.
26. Chappell LC, Brocklehurst P, Green ME, et al. Planned early delivery or
expectant management for late preterm pre‐eclampsia (PHOENIX): A
randomised controlled trial. Lancet. 2019;394:1181–1190.
27. Souza MA, Guida JPS, Cecatti JG, et al. Analgesia during Labor
and vaginal birth among women with severe maternal morbidity:
Secondary analysis from the WHO Multicountry Survey on Maternal
and Newborn Health. Biomed Res Int. 2019;2019:7596165.