Sevened2023 004-046

CHAPTER 46
The Robson Classification as an evaluation of the cesarean section rate in the

regions of Brazil and the relationship with the infant mortality rate
South, and Midwest. Data were electronically

https://doi.org/10.56238/sevened2023.004-046 obtained from the Health Department (DATASUS)
of the Brazilian Unified Health System (SUS) using
Nicolle Albuquerque Miott the TABNET application. RESULTS: Our findings
Medical student suggest that patients aged 20 to 24 years old who fall
Cesumar University – UNICESUMAR into group 3 of Robson's classification are the most
prevalent in Brazil then the others and They are who
Lívia Dalla Vechia have a highest chance of vaginal delivery).
Medical student Therefore, it can be inferred that there was an option
Cesumar University- UNICESUMAR for cesarean section and not a medical indication.
Regarding newborns, it is also necessary to note that
Adriana Cunha Vargas in the first and second minute of life, the Apgar
Doctor
score with the highest occurrence was 8-10,
Cesumar University- UNICESUMAR
indicating that most babies were born with good
ABSTRACT vitality. Furthermore, the most prevalent birth
INTRODUCTION: Most childhood deaths are weight was between 3000 and 3999 grams, which,
according to the Ministry of Health, indicates the
concentrated in the first year of life, above all in the
first month. There is a high participation of perinatal ideal weight for a healthy newborn. Moreover, it is
causes such as prematurity, by which highlights the worth noting that despite the highest infant mortality
importance of factors related to pregnancy, rates occurring onto 0-6 days period, we can infer
childbirth, and postpartum, generally preventable that something during childbirth may have
with quality assistment healthcare. OBJECTIVE: To contributed to this statistic, such as an incorrect
analyze the prevalence of cesarean section rates indication for cesarean section. CONCLUSION: It
according to Robson's classification in each region is common knowledge that vaginal delivery offers
of Brazil and relate it with infant mortality rate. numerous (a several) benefits to the newborn, as in
terms of immunity such as for the mother during the
METHODOLOGY: This is a quantitative,
observational, cross-sectional, and descriptive postpartum period.
study. The study involved 7,194,258 Brazilian
women aged 20 to 24 years from 2012 to 2021. The Keywords: Robson classification, Cesarean, Infant
study was conducted in Brazil, covering all five Mortality, Indicators of Morbidity and Mortality.
regions of the country: North, Northeast, Southeast,
1 INTRODUCTION
"Most childhood deaths are concentrated in the first year of life, especially in the first month.
There is a high participation of perinatal causes such as prematurity, which highlights the importance
of factors related to pregnancy, childbirth and postpartum, which are generally preventable through
quality health care" (LANSKY S, 2014).
It is known that the choice of natural childbirth is extremely important for the health of the
newborn, due to factors related to the physiological process from birth to the immunological
development provided, among many other benefits (RAYMAN M, 2019). Thus, the percentage of
Health and Medicine: Science, Care, and Discoveries

The Robson Classification as an evaluation of the cesarean section rate in the regions of Brazil and the
relationship with the infant mortality rate
cesarean sections indicated by the World Health Organization (WHO) is 15%. However, in Brazil, this
number grows to 56%, being the world leader in cesarean sections, becoming an "epidemic". In the
private network, this margin is increased, reaching the mark of 89% (FIOCRUZ, 2021).
In 20 years, there has been an increase worldwide in cesarean deliveries, on average, in Europe
the rate is 20% to 22%, in the United States it rises to 32.8%, but still below the rate in Brazil (UNA-
SUS, 2015).
Data from the information system on live births (Sinasc) referring to births in 2016 indicate the
Brazilian states with the highest rates of cesarean delivery: Goiás (67%), Espírito Santo (67%),
Rondônia (66%), Paraná (63%) and Rio Grande do Sul (63%) (GUEDES, 2018).
This procedure indicates that there is a higher risk of infant mortality in 25% of children up to
5 years of age compared to those born vaginally. However, when cesarean section is recommended by
the physician due to risk factors, the death rate decreases (LARANJEIRA, 2021).
The infant mortality rate, or coefficient, is an estimate of the risk of death to which a population
of live births is exposed in a given area and period before completing the first year of life (PEREIRA,
1995). Infant mortality can be divided into early neonatal (0-6 days of life), late neonatal (7-27 days)
and post-neonatal (28 days or more) (PALHANO, 2017).
The epidemic of cesarean deliveries, largely without indication for medical reasons (therapeutic
cesarean section), helps to increase the infant mortality rate, pointing to the need to reassess the
cesarean section rate, through the implementation of a standard instrument, proposed by the World
Health Organization (WHO), the Robson Classification (LINS, 2021).
The Robson Classification was created by the Irish physician Michael Robson in 2001 with the
aim of prospectively identifying clinically relevant groups of women in which there are differences in
cesarean section rates and thus allowing comparisons within the same institution over time or between
different institutions (WORLD HEALTH ORGANIZATION, 2015).
The Robson Classification uses 10 groups and 6 obstetric concepts, namely: parity, previous
cesarean section, onset of labor, gestational age, fetal presentation, and number of fetuses. The
classification is totally inclusive and mutually exclusive, i.e., all pregnant women are included in only
1 of the 10 groups (NAKAMURA- PEREIRA M, 2016).
It is essential to portray the usefulness of the Robson Classification: in addition to being simple,
robust and reproducible, it is clinically relevant and prospective. The World Health Organization in
2011 concluded, in a systematic review, that it is the most appropriate classification for local and
international needs. (FIOCRUZ, 2018)
To the best of our knowledge, there are no articles relating the cesarean section rate based on
Robson's classification to neonatal mortality. It is inferred, therefore, that there are several variables
that justify the increase of this practice without correct indications in Brazil. Therefore, the objective

of this study is to analyze the prevalence of cesarean section rates according to Robson's classification
in each region of Brazil and to relate it to the infant mortality rate.
2 METHODOLOGY
This is a quantitative, observational, cross-sectional and descriptive study. The study involved
7,194,258 Brazilian women aged between 20 and 24 years, since this age group is associated with
lower risk during pregnancy. In order to analyze the causes of the incidence of cesarean deliveries in
the period from 2012 to 2021, to understand the possible reasons behind the growing preference for
the cesarean section method, and to identify the infant mortality rate taking into account the most recent
data available, the study was conducted in Brazil, covering the five regions of the country: North,
Northeast, Southeast, South and Midwest.
The infant mortality rate was calculated based on the equation: number of deaths of children
under 1 year of age in the period divided by the number of live births in the period multiplied by 1,000.
This calculation is used internationally to define the indicator of quality of life and development of a
given population, it is a very sensitive indicator of social, economic and health inequity (UFSC, 2017).
Data related to variables related to the mother and newborn were obtained electronically from
the Health Department (DATASUS) of the Unified Health System (SUS) in Brazil, using the TABNET
application, a generic tabulator in the public domain that allows data to be organized according to the
requested query to obtain various information within the SUS.
Initially, data collection was carried out on women aged between 20 and 24 years, from the
five different regions of Brazil, totaling 7,194,258 participants. Thus, several aspects were evaluated,
including schooling, race, Robson classification and the analysis of their respective newborns,
including information such as weight, sex, Apgar score in the first and second minute, birth weight
and type of delivery.
The second period was used for comparison purposes, in order to verify the characteristics of
pregnant women in relation to the characteristics of newborns. The choice of this target audience is
due to the intention of analyzing the trend in the behavior of opting for cesarean sections without
medical indication and its impact on live births and infant mortality rates in different regions of Brazil.
The data were consolidated in an Excel spreadsheet and, subsequently, were discussed in a
descriptive way, analyzing the collected numbers and comparing those with higher and lower
prevalence, in order to generate a conclusion about the proposed theme. The present study followed
the ethical procedures according to Resolution No. 466/2012 CNS, however, it used public databases
(http://datasus.saude.gov.br/).

3 RESULTS
During the study period, 7,194,258 women participated in the Robson classification. The most
prevalent education in Brazil was from 8 to 11 years old (69.7%), with the highest rate in the Southeast
region being 39.7%. The least prevalent were those with no schooling (0.3%), with a predominance
in the North region (42.1%).
Regarding race, the highest percentage of mothers who had children was brown, in the
Northeast region 39.1%. On the other hand, those who had fewer children were considered yellow,
with the lowest rate in the southern region: 6.7%.
Finally, with regard to Robson's classification, the highest rate of deliveries occurred in
nulliparous women, singleton pregnancies, cephalic pregnancies, <37 weeks, and spontaneous labor,
totaling 35.2% in the Northeast region. While the lowest percentage was of women who had all
abnormal presentations (including previous cesarean section), with the Midwest region having the
lowest rate (6.7%).
Table 1 - Identification data of mothers who presented Robson classification in the period from 2012 to 2021. Brazil, 2023.
North Northeast Southeast South Midwest Brazil
VARIABLE N % n % n % n % n % N
Mother's Instruction
No 8708 42, 7613 37 2198 10, 814 3,9 1340 6,5 20673 0,3
1 6
1 to 3 years 3176 6,6 62763 47, 21529 16, 8859 6,7 7027 5,3 13194 1,8
4 6 3 2
4 to 7 years 1994 16, 47174 38, 33568 27, 1504 12, 8330 6,7 12406 17,2
65 1 6 0 0 1 90 1 2 83
8 to 11 years 5768 11, 13828 27, 19888 39, 6405 12, 4250 8,5 50141 69,7
59 5 16 6 15 7 93 8 59 42
12 years and older 7153 10, 14893 22, 25264 37, 1090 16, 8838 13, 67055 9,3
4 7 3 2 1 7 68 3 1 2 7
Ignored 1820 15, 57885 49, 30286 26, 3938 3,4 5947 5,1 11626 1,6
5 7 8 1 1
Total 9065 12, 21317 29, 26311 36, 9137 12, 6110 8,5 71942 100,
35 6 56 6 49 6 62 7 56 58 0
Race
White 6373 3,0 20971 9,7 10492 48, 6995 32, 1354 6,3 21577 30,0
2 7 77 6 97 4 22 45
Black 2081 5,0 10721 25, 21694 52, 4377 10, 2606 6,3 41480 5,8
1 4 8 7 3 5 6 1 8
Yellow 2180 8,6 6901 27, 10772 42, 1701 6,7 3778 14, 25332 0,4
2 5 9
Curtain 7698 18, 16739 39, 12953 30, 1529 3,6 3888 9,1 42809 59,5
18 0 20 1 87 3 64 25 14
Indigenous 3563 53, 10735 16, 5114 7,7 4010 6,1 1067 16, 66163 0,9
3 9 2 1 1
Ignored 1436 5,8 12326 49, 53652 21, 1171 4,7 4629 18, 24929 3,5
1 9 4 5 5 9 6 6
Total 9065 12, 21317 29, 26311 36, 9137 12, 6110 8,5 71942 100
35 6 56 6 49 6 62 7 56 58
Robson's Classification

01 Increase 1583 12, 43387 35, 40218 32, 1270 10, 1098 8,9 12313 17,1
d 61 9 0 2 9 7 51 3 70 41
chance
of
vaginal
delivery
02 Increase 4960 5,3 17819 19, 45658 49, 1785 19, 6714 7,0 93003 12,9
d 1 2 2 6 1 06 2 9 4
chance
of
vaginal
delivery
03 Increase 2103 17, 41179 35, 34879 29, 1094 9,3 9658 8,2 11769 16,4
d 65 9 5 0 0 6 11 4 45
chance
of
vaginal
delivery
04 Increase 3548 7,8 97115 21, 21246 46, 7694 16, 3209 7,1 45410 6,3
d 5 4 6 8 2 9 7 5
chance
of
vaginal
delivery
05 Some 1229 12, 25600 26, 35379 36, 1321 13, 9999 10, 96489 13,4
chance 36 7 8 5 9 7 58 7 6 4 7
of
vaginal
delivery
06 Lower 7749 9,9 21692 27, 29106 37, 1248 15, 7595 9,7 78626 1,1
chance 6 0 4 9
of
vaginal
delivery
07 Lower 1185 15, 23826 30, 23703 30, 9646 12, 8120 10, 77147 1,1
chance 2 4 9 7 5 5
of
vaginal
delivery
08 Lower 9869 10, 25624 28, 35126 38, 1189 13, 7771 8,6 90284 1,3
chance 9 4 9 4 2
of
vaginal
delivery
09 Lower 1721 17, 3152 31, 2995 29, 1511 15, 675 6,7 10054 0,1
chance 1 4 8 0
of
vaginal
delivery
10 Lower 6811 14, 14334 29, 17056 35, 5734 12, 3973 8,3 47909 6,7
chance 2 2 0 9 1 6 8 0 1 2
of
vaginal
delivery
11 4654 22, 89112 43, 41700 20, 1032 5,0 1812 8,8 20580 2,9
1 6 3 3 1 8 2
Not informed 1839 12, 44803 29, 55412 37, 1864 12, 1233 8,2 14959 20,8
43 3 0 9 8 0 90 5 40 31
Total 9065 12, 21317 29, 26311 36, 9137 12, 6110 8,5 71942 100
35 6 56 6 49 6 62 7 56 58
Source: own authorship

North Northeast Southeast South Midwest Brazil
VARIABLE N % n % n % n % n % N
Mother's Instruction
No 8708 42, 7613 37 2198 10, 814 3,9 1340 6,5 20673 0,3
1 6
1 to 3 years 3176 6,6 62763 47, 21529 16, 8859 6,7 7027 5,3 13194 1,8
4 6 3 2
4 to 7 years 1994 16, 47174 38, 33568 27, 1504 12, 8330 6,7 12406 17,2
65 1 6 0 0 1 90 1 2 83
8 to 11 years 5768 11, 13828 27, 19888 39, 6405 12, 4250 8,5 50141 69,7
59 5 16 6 15 7 93 8 59 42
12 years and older 7153 10, 14893 22, 25264 37, 1090 16, 8838 13, 67055 9,3
4 7 3 2 1 7 68 3 1 2 7
Ignored 1820 15, 57885 49, 30286 26, 3938 3,4 5947 5,1 11626 1,6
5 7 8 1 1
Total 9065 12, 21317 29, 26311 36, 9137 12, 6110 8,5 71942 100,
35 6 56 6 49 6 62 7 56 58 0
Race
White 6373 3,0 20971 9,7 10492 48, 6995 32, 1354 6,3 21577 30,0
2 7 77 6 97 4 22 45
Black 2081 5,0 10721 25, 21694 52, 4377 10, 2606 6,3 41480 5,8
1 4 8 7 3 5 6 1 8
Yellow 2180 8,6 6901 27, 10772 42, 1701 6,7 3778 14, 25332 0,4
2 5 9
Curtain 7698 18, 16739 39, 12953 30, 1529 3,6 3888 9,1 42809 59,5
18 0 20 1 87 3 64 25 14
Indigenous 3563 53, 10735 16, 5114 7,7 4010 6,1 1067 16, 66163 0,9
3 9 2 1 1
Ignored 1436 5,8 12326 49, 53652 21, 1171 4,7 4629 18, 24929 3,5
1 9 4 5 5 9 6 6
Total 9065 12, 21317 29, 26311 36, 9137 12, 6110 8,5 71942 100
35 6 56 6 49 6 62 7 56 58
Robson's Classification
01 Increase 1583 12, 43387 35, 40218 32, 1270 10, 1098 8,9 12313 17,1
d 61 9 0 2 9 7 51 3 70 41
chance
of
vaginal
delivery
02 Increase 4960 5,3 17819 19, 45658 49, 1785 19, 6714 7,0 93003 12,9
d 1 2 2 6 1 06 2 9 4
chance
of
vaginal
delivery
03 Increase 2103 17, 41179 35, 34879 29, 1094 9,3 9658 8,2 11769 16,4
d 65 9 5 0 0 6 11 4 45
chance
of
vaginal
delivery
04 Increase 3548 7,8 97115 21, 21246 46, 7694 16, 3209 7,1 45410 6,3
d 5 4 6 8 2 9 7 5
chance
of
vaginal
delivery
05 Some 1229 12, 25600 26, 35379 36, 1321 13, 9999 10, 96489 13,4
chance 36 7 8 5 9 7 58 7 6 4 7
of

vaginal
delivery
06 Lower 7749 9,9 21692 27, 29106 37, 1248 15, 7595 9,7 78626 1,1
chance 6 0 4 9
of
vaginal
delivery
07 Lower 1185 15, 23826 30, 23703 30, 9646 12, 8120 10, 77147 1,1
chance 2 4 9 7 5 5
of
vaginal
delivery
08 Lower 9869 10, 25624 28, 35126 38, 1189 13, 7771 8,6 90284 1,3
chance 9 4 9 4 2
of
vaginal
delivery
09 Lower 1721 17, 3152 31, 2995 29, 1511 15, 675 6,7 10054 0,1
chance 1 4 8 0
of
vaginal
delivery
10 Lower 6811 14, 14334 29, 17056 35, 5734 12, 3973 8,3 47909 6,7
chance 2 2 0 9 1 6 8 0 1 2
of
vaginal
delivery
11 4654 22, 89112 43, 41700 20, 1032 5,0 1812 8,8 20580 2,9
1 6 3 3 1 8 2
Not informed 1839 12, 44803 29, 55412 37, 1864 12, 1233 8,2 14959 20,8
43 3 0 9 8 0 90 5 40 31
Total 9065 12, 21317 29, 26311 36, 9137 12, 6110 8,5 71942 100
35 6 56 6 49 6 62 7 56 58
Legend:
1. Nulliparous, singleton pregnancy, cephalic, >37 weeks, spontaneous labor
2. Nulliparous, single pregnancy, cephalic, >37 weeks, with indication of cesarean section before labor
3. Multiparous, (no previous cesarean section) singleton pregnancy, cephalic, >37 weeks, spontaneous
4. Multiparous, (no previous cesarean section) single pregnancy, cephalic, >37 weeks, indicated cesarean section
before labor
5. With previous cesarean section, single pregnancy, cephalic, >37 weeks
6. All breech births in nulliparous women
7. All breech births in multiparous women (including previous cesarean section)
8. All multiple pregnancies (including previous cesarean section)
9. All abnormal presentations (including previous cesarean section)
10. All singleton pregnancies, cephalic, <36 weeks, including previous cesarean section
11. Births not classified due to lack of response to the necessary items
Regarding the identification of newborns in the different regions of Brazil, males accounted
for 51.2%, with the highest rate in the Northeast region, corresponding to 29.6%. While the female
gender was 48.7%, with a predominance also in the Northeast region, 29.6%.
The Apgar score at 1st minute in Brazil obtained the highest score from 8 to 10 (85.6%), with
the most prevalent region being the southeast, with 37.1%. The lowest score was between 0 and 2, with
0.7%, and the Central-West region was the least prevalent, with 7.1%. In the 2nd minute, the Apgar
score in Brazil was (95.3%), with a score between 8 and 10, and the highest rate was 37.1% in the

Southeast region. The region with the lowest percentage was the Midwest, with 7.5%, and scores
between 3 and 5.
Regarding the weight of the newborn, (64.7%) were born weighing between 3,000g and 3,999g,
with 35.7% being more prevalent in the Southeast region. While the lowest percentage was less than
500g, in the Midwest region 6.8%.
Regarding the type of delivery in Brazil, (50.8%) were vaginal deliveries, with the highest
incidence in the Southeast region (35.6%) and (49.1%) were cesarean sections, also with a
predominance in the Southeast region (37.6%). The region with the Regarding the type of delivery in
Brazil, (50.8%) were vaginal deliveries, with the highest incidence in the Southeast region (35.6%)
and (49.1%) were cesarean sections, also with a predominance in the Southeast region (37.6%). The
region with the lowest rate of cesarean section was the Midwest, 9.1%, and the lowest rate of vaginal
deliveries was also in the Central-West region, 7.2%.
Table 2. RN identification data from 2012 to 2021. Brazil, 2023.

VARIABLE North Northeast Southeast On Midwest Brazil
n % n % n % n % n % N %
sex
Mask 46486 12, 109290 29, 134735 36, 46864 12, 31272 8,4 368650 51,
9 6 9 6 6 5 9 7 6 9 2
Five 44153 12, 103834 29, 128338 36, 44501 12, 29817 8,5 350644 48,
8 6 6 6 1 6 3 7 0 8 7
Ign 128 9,8 501 38, 412 31, 100 7,7 160 12, 1301 0,0
5 7 2 2
Total 90653 12, 213175 29, 263114 36, 91376 12, 61105 8,4 719425 100
5 6 6 6 9 6 2 7 6 8
Apgar 1st minute
0a2 5203 10, 14712 28, 20396 39, 7856 15, 3679 7,1 51846 0,7
0 4 3 2
3a5 16526 8,9 57350 31, 72617 39, 25255 13, 13118 7,1 184866 2,6
0 3 7
6a7 77315 12, 198420 32, 211452 34, 78389 12, 52936 8,6 618512 8,6
5 1 2 7
8 a 10 77123 12, 176618 28, 228640 37, 79713 12, 53460 8,6 615556 85,
9 5 8 7 2 1 7 9 3 9 6
Ignored 36252 19, 95086 51, 40282 22, 5125 2,8 6720 13, 183465 2,6
8 8 0 0
Total 90653 12, 213175 29, 263114 36, 91376 12, 61105 8,4 719425 100
5 6 6 6 9 6 2 7 6 8
Apgar 2nd minute
0a2 2654 13, 6507 33, 6816 34, 2080 10, 1479 7,6 19536 0,3
6 3 9 6
3a5 3034 10, 9049 32, 9962 35, 3624 13, 2087 7,5 27756 0,4
9 6 9 1
6a7 11570 10, 34996 33, 36756 34, 14206 13, 8470 7,9 105998 1,5
9 0 7 4
8 a 10 85211 12, 198503 28, 253985 37, 88888 13, 59233 8,6 685822 95,
3 4 6 9 3 0 5 0 6 3 3
Ignored 37164 20, 96168 52, 37762 20, 4967 2,7 6684 3,6 182745 2,5
3 6 7

Total 90653 12, 213175 29, 263114 36, 91376 12, 61105 8,5 719425 100
5 6 6 6 9 6 2 7 6 8
Weight
Less than 500g 1123 11, 3939 41, 3009 31, 876 9,1 651 6,8 9598 0,1
7 0 4
500 to 999g 2934 9,4 8642 27, 13109 42, 4045 13, 2487 7,9 31217 0,4
7 0 0
1000 a 1499 g 4886 10, 12601 27, 18777 40, 6018 13, 3732 8,1 46014 0,6
6 4 8 1
1500 a 2499 g 53002 11, 129137 27, 186038 39, 60178 12, 39600 8,4 467955 6,5
3 6 8 9
2500 a 2999 g 19501 11, 452112 27, 642654 39, 20703 12, 14532 8,8 164214 22,
6 9 5 1 9 6 4 5 8
3000 a 3999 g 59870 12, 140330 30, 166234 35, 59274 12, 39402 8,4 465112 64,
3 9 5 2 8 7 8 7 1 5 7
4000g and 48792 14, 121242 35, 105097 30, 42816 12, 25040 7,3 342987 4,8
more 2 3 6 5
Ignored 2079 64, 778 24, 117 3,6 42 1,3 201 6,2 3217 0,0
6 2
Total 90653 12, 213175 29, 263114 36, 91376 12, 61105 8,5 719425 100
5 6 6 6 9 6 2 7 6 8
Type of delivery
Vaginal 50859 13, 115830 31, 130214 35, 42189 11, 26468 7,2 365562 50,
7 9 4 7 4 6 7 5 6 8 8
Cesario 39682 11, 969364 27, 132667 37, 49141 13, 34576 9,7 353003 49,
6 2 5 3 6 1 9 3 7 1
Ignored 1112 12, 4088 47, 2332 27, 454 5,3 607 7,1 8593 0,1
9 6 1
Total 90653 12, 213175 29, 263114 36, 91376 12, 61105 8,5 719425 100
5 6 6 6 9 6 2 7 6 8
Among the live births in Brazil, data were collected from 361,047 who died in the year 2012
to 2021. It is possible to see that the region with the highest number of live births is the southeast
(36.6%). In relation to mortality, the Northeast continues to have infant mortality leading among the
regions (53.7%). On the other hand, the Midwest continues to have the lowest rates of live births
(8.5%) and infant mortality, the South has the lowest number when compared to the others (43.3%)
The year with the highest rates of live births was 2012 (10.5%) compared to 2021 (9.2%). In
relation to mortality, it is possible to associate the time from o to 6 days (26.5%) as the highest index
when compared to the other age groups, on the other hand, the age of less than 1 year (ign) is the lowest
rate (0.01%).
Table 3. Relationship of live births with infant mortality from 2012 to 2021. Brazil
VARIABLE North Northeast Southeast On C.West Total
n % n % n % n % n % N %
Live births
2012 91813 12, 229054 30, 281147 37, 93457 12,3 61525 8, 756996 10,
1 3 1 5 1 5
2013 92130 12, 218976 29, 272981 36, 93033 12,5 61815 8, 738935 10,
5 6 9 9 4 3
2014 93913 12, 217620 29, 275989 37, 94240 12,6 63245 8, 745007 10,
6 2 0 5 5 4

2015 93044 12, 219572 29, 278542 37, 96873 12,8 63638 8, 751669 10,
4 2 1 9 5 4
2016 89869 12, 212364 29, 265309 36, 92244 12,7 61515 8, 721301 10,
5 4 8 9 5 0
2017 90303 12, 215697 29, 267857 36, 93314 12,7 62947 8, 730118 10,
4 5 7 8 6 1
2018 92089 12, 216271 29, 261565 36, 91392 12,6 62035 8, 723352 10,
7 9 2 3 6 1
2019 89599 12, 206544 29, 252526 36, 88670 12,7 60139 8, 697478 9,7
8 6 2 1 6
2020 86021 12, 198088 29, 242318 36, 86550 12,9 57412 8, 670389 9,3
8 5 1 1 6
2021 87754 13, 197570 30, 232915 35, 83989 12,7 56785 8, 659013 9,2
3 0 3 4 6
Total 90653 12, 213175 29, 263114 36, 91376 12,7 61105 8, 719425 100
5 6 6 6 9 6 2 6 5 8
Infant mortality
0 to 6 days 25115 27, 63979 30, 65414 24, 20617 22,6 15584 25 190709 26,
7 0 9 5
7 to 27 days 7193 7,9 17769 8,3 24251 9,2 7549 8,3 5032 8, 61794 8,6
2
28 to 364 days 16160 17, 32820 0,0 39403 15, 11353 12,4 8768 14 108504 15,
8 0 1
Younger 1 year 4 0,0 7 0,0 13 0,0 4 0,0 12 0, 40 0,0
(ign) 0
Total 48472 53, 114575 53, 129081 49, 39523 43,3 29396 48 361047 50,
5 7 1 2
Table 4 shows a relationship between 7,194,258 women, most of whom fit into one of Robson's
10 groups, with infant mortality. Thus, it is possible to observe that the North (22.6%) and the Northeast
(43.3%) had higher rates of women in whom childbirth could not be classified due to lack of response
to the items necessary to enter any of the groups. It is also noteworthy that in the Southeast (49.1%)
and South (19.2) the most prevalent Robson group was group 2, while in the Midwest (10.5%) it was
group 7.
In addition, with regard to infant mortality, the region with the highest infant mortality rates
was the Northeast (53.7%) and the one with the lowest rates is the South (43.3%). It should also be
noted that the age group with the highest mortality rates was from 0 to 6 days (26.5%), as opposed to
the age group of children under 1 year (ign) with extremely low rates (0.01%).
Table 4. Relationship of women who fit into the Robson Classification with infant mortality in the period from 2012 to
2021. Brazil
VARIABLE North Northeast Southeast On C. West Total
n % n % n % n % n % n %
Robson's Groups
01 Increased chance of 1583 12, 43387 35, 40218 32, 1270 10, 1098 8,9 12313 17,
vaginal delivery 61 9 0 2 9 7 51 3 70 41 1
02 Increased chance of 4960 5,3 17819 19, 45658 49, 1785 19, 6714 7,2 93003 12,
vaginal delivery 1 2 2 6 1 06 2 9 4 9
03 Increased Chance of 2103 17, 41179 35 34879 29, 1094 9,3 9658 8,2 11769 16,
Vaginal Delivery 65 9 5 0 6 11 4 45 4

04 Increased Chance of 3548 7,8 97115 21, 21246 46, 7694 16, 3209 7,1 45410 6,3
Vaginal Delivery 5 4 6 8 2 9 7 5 1
05 Some Chance of Vaginal 1229 12, 25600 26, 35379 36, 1321 13, 9999 10, 96489 13,
Delivery 36 7 8 5 9 7 58 7 6 4 7 4
06 Lower chance of vaginal 7749 9,9 21692 27, 29106 37 1248 15, 7595 9,7 78626 1,0
delivery 6 4 9 9
07 Lower Chance of Vaginal 1185 15, 23826 30, 23703 30, 9646 12, 8120 10, 77147 21,
Delivery 2 4 9 7 5 5 4
08 Lower Chance of Vaginal 9869 10, 25624 28, 35126 38, 1189 13, 7771 8,6 90284 1,2
Delivery 9 4 9 4 2 5
09 Lower Chance of Vaginal 1721 17, 3152 31, 2995 29, 1511 15 675 6,7 10054 0,1
Delivery 1 4 8 4
10 Lower chance of vaginal 6811 14, 14334 29, 17056 35, 5734 12 3973 8,3 47909 6,6
delivery 2 2 0 9 1 6 8 1 2 6
11 4654 22, 89112 43, 41700 20, 1032 5,0 1812 8,8 20580 2,8
1 6 3 3 1 8 2 6
Not informed 1839 12, 44803 29, 55412 37 1864 12, 1233 8,2 14959 20,
43 3 0 9 8 90 5 40 31 8
Total 9065 12, 21317 29, 26311 36, 9137 12, 6110 8,5 71942 10
35 6 56 6 49 6 62 7 56 58 0
Infant mortality
0 to 6 days 2511 27, 63979 30, 65414 24, 2061 22, 1558 25, 19070 26,
5 7 0 9 7 6 4 5 9 5
7 to 27 days 7193 7,9 17769 8,3 24251 9,2 7549 8,3 5032 8,2 61794 8,6
28 to 364 days 1616 17, 32820 0,0 39403 15, 1135 12, 8768 14, 10850 15,
0 8 0 3 4 3 4 1
Younger 1 year (ign) 4 0,0 7 0,0 13 0,0 4 0,0 12 0,0 40 0,0
Total 4847 53, 11457 53, 12908 49, 3952 43, 2939 48, 36104 50,
2 5 5 7 1 1 3 3 6 1 7 2
Caption:
1. Nulliparous, singleton pregnancy, cephalic, >37 weeks, spontaneous labor
2. Nulliparous, single pregnancy, cephalic, >37 weeks, with indication of cesarean section before labor
3. Multiparous, (no previous cesarean section) singleton pregnancy, cephalic, >37 weeks, spontaneous
4. Multiparous, (no previous cesarean section) single pregnancy, cephalic, >37 weeks, indicated cesarean section
before labor
5. With previous cesarean section, single pregnancy, cephalic, >37 weeks
6. All breech births in nulliparous women
7. All breech births in multiparous women (including previous cesarean section)
8. All multiple pregnancies (including previous cesarean section)
9. All abnormal presentations (including previous cesarean section)
10. All singleton pregnancies, cephalic, <36 weeks, including previous cesarean section
11. Births not classified due to lack of response to the necessary items
4 DISCUSSION
Studies relating the cesarean section rate based on Robson's classification to neonatal mortality
are still scarce, although they are essential for understanding the infant mortality rate. This type of
analysis contributes to the orientation of research and intervention programs on determinants of infant
mortality, reinforcing the potential of the public health system for prevention and health promotion in
the different regions of a country of continental dimensions such as Brazil, which can be extrapolated
to similar countries.
Our findings suggest that patients aged 20 to 24 years who fall into group 3 of Robson's
classification are the most prevalent in Brazil among the others and are the ones with the highest chance

of vaginal delivery. Therefore, it can be inferred that there was an option for cesarean section and not
a necessity. It is also possible to observe that the place where Robson's group 3 prevailed was in the
Northeast, where the most prevalent level of maternal education was from 1 to 3 years old (47.6%)
and the race with the highest numbers was Brown (39.1%), whether it is associated with the choice of
the woman or the obstetric indication is not known. Something similar occurred in a study carried out
in Honduras regarding the Robson Classification, which related the rates with the importance of
induced labor and showed that the group that most prevailed was also 1, 3 and 5, as well as in Brazil,
and showed that if these data were analyzed, an alternative could be found that would reduce cesarean
deliveries without need. (BANEGAS, 2022)
It is also possible to observe in relation to the NB that the rates of cesarean section and vaginal
delivery are very similar, with the latter being slightly higher, with males having the highest numbers
in relation to females. Regarding this NB, it is also necessary to relate that in the first and second
minute of life of the individuals the APGAR score that had the highest rates of occurrence was that of
8-10, which indicates that most were born with good vitality. And, to top it off, the weight that most
prevailed was 3000 to 3999 grams, which, according to the Ministry of Health, shows that it is ideal
for a healthy newborn. (MINISTRY OF HEALTH, 2012)
In addition, it is noteworthy that, despite what has been shown, the highest infant mortality
rates are found in the period of 0-6 days, we can infer that something that occurred during childbirth
may have caused such a statistic, such as, for example, an indication of incorrect cesarean section. As
an example, we have the North region, which, despite having the second lowest rate of live births, has
the second highest rate of infant mortality, with emphasis on the period already mentioned. Analyzing
the Northeast, it is possible to see that it has the highest infant mortality rates among the regions, and
the Robson Group that most prevailed was group 1, which had the highest chances of a successful
vaginal delivery and even so, the Apgar score that had the highest numbers was 6-7 in the first minute
and 0-2 in the second minute. and weighing less than 500g.
However, despite the above, given the impossibility of going to the field to collect all the
information necessary for this article because it is a national study with several indicators, it is
necessary to mention that the research has limitations in relation to the database, which, as it is a
resource with information from all regions of the country, requires constant updating. Thus, in addition
to finding several indicators with the highest rates being in uncollected data, it was necessary to collect
a long period to be able to work with larger values and acquire a more complete result.
Thus, it is vital that the subject addressed in the following work serves as a basis for further
research so that the content of the theme remains updated, an example of how this can be done is by
investigating more deeply within each region the reason for deaths in the first days of the newborn's
life and even the cause of cesarean sections being performed in women who are part of Robson groups

that have chances vaginal delivery. In this way, knowledge about this topic that is so relevant today
will be expanded.
5 CONCLUSION
It is common sense that vaginal delivery has numerous benefits for the newborn, both in terms
of immunity and for the mother in the postpartum period. The increase in the mortality rate is due to
the inadequate choice of cesarean sections and the reduction in vaginal deliveries. This research
demonstrated from Robson's classification that the frequency of mortality is still growing and
children's health problems are increasing. Therefore, it is necessary to develop viable strategies to
reverse this growing trend in infant mortality, caused by the inadequate choice of the type of delivery,
starting with increased investments in information, so that infant mortality rates decrease.

REFERENCES
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ferramenta para redução das taxas de cesariana: uma revisão de literatura, Universidade Federal de
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https://unasus2.moodle.ufsc.br/pluginfile.php/33455/mod_resource/content/1/un2/top4_1.html,
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out. 2023


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CHAPTER 46

The Robson Classification as an evaluation of the cesarean section rate in the

South, and Midwest. Data were electronically

Health and Medicine: Science, Care, and Discoveries

Health and Medicine: Science, Care, and Discoveries

Health and Medicine: Science, Care, and Discoveries

Health and Medicine: Science, Care, and Discoveries

Health and Medicine: Science, Care, and Discoveries

Health and Medicine: Science, Care, and Discoveries

Health and Medicine: Science, Care, and Discoveries

Table 2. RN identification data from 2012 to 2021. Brazil, 2023.

Health and Medicine: Science, Care, and Discoveries

Health and Medicine: Science, Care, and Discoveries

Health and Medicine: Science, Care, and Discoveries

Health and Medicine: Science, Care, and Discoveries

Health and Medicine: Science, Care, and Discoveries

Health and Medicine: Science, Care, and Discoveries

ALMEIDA LINS, J, A aplicação da classificação de robson nas maternidades brasileiras como

BOING, A, F, et al. Epidemiologia: indicadores de Saúde, UNA-SUS, 2008, Disponível em:

Classificação de Robson, Fiocruz, 2018, Disponível em: https://portaldeboaspraticas.iff.fiocruz.br,

Brasil. Ministério da Saúde. Secretaria de Atenção à Saúde. Departamento de Ações Programáticas

Health and Medicine: Science, Care, and Discoveries

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