The CS rate found in the PP was similar to that estimated by the c-model tool, as well as to a database with low CS rates and good perinatal outcomes, such as Sweden17. For countries with high CS rates, such as Brazil, differences between rates observed and estimated by the c-model are usually higher.16,18−20 The groups that most contributed to a lower rate in the PP were groups 2 (particularly group 2a) and 5, a result that also differs from the rates found in the WHO Global Survey of Maternal and Perinatal Health study.21
Women of the PP population had predominantly a single child, with a low natality rate, since they presented a proportion of NTSV greater than the expected by the WHO; this group had low rates of induction of birth and pre-labour CS, reinforcing that such interventions were performed only for medical reasons.2,22
Group 5 contributed to 14.9% of the population, and its size is related to the general population CS rate. The important size of group 5 reflects a longer-than-expected history of CSs, as it is represented by women nulliparous in their previous pregnancy who underwent a CS. In places with low cesarean rates, it usually contributes to less than 10% of women 2.
The CS rates of this PP were lower than those of other Brazilian studies published for all Robson groups, considering both the public and private sectors, including teaching hospitals, that should adopt the evidence-based protocols of the Brazilian Ministry of Health.23–26 Studies that evaluated the quality of obstetric care practiced in the country evinced an excessively interventionist practice, e.g., absence of evidence-based protocol use, with intervention rates even higher in high-income locations, with no improvement in the quality of maternity services and with increases in both the risk of iatrogenic harm and costs.27–30
According to the WHO, half of all CSs occur in group 5; PP Group 5 displayed a CS rate of 20.5%, representing 20% of all CSs performed. For Group 5, cesarean rates between 50 and 60% are expected.2,22
This rate contrasts even more when compared to a private population of cases eligible for vaginal birth after a cesarean section, which had an elective CS rate of 95.3% and 39,2% of intrapartum CS in this group, suggesting that nonclinical factors are leading to CS iteration in these services.23
The significantly lower rates obtained in the PP may be due to: use of evidence-based protocols; women's desire for a vaginal birth, professionals enabling all measures to facilitate it; continuous support for women during childbirth; and, for women in group 5, the willingness of both the woman and the professionals to allow a trial of labour; and the absence of obstetric indication for the previous CS, typical of populations with high cesarean rates31.
The collaborative and multidisciplinary model, involving obstetricians and midwives, is an effective and successful model for the improvement of obstetric care (including high-risk cases), reducing adverse perinatal events and increasing safety and women’s satisfaction with her birth; it encourages a patient- and family-centered practice and is tuned to the WHO recommendations for a positive childbirth experience. A study that compared the prevalence of CS and neonatal outcomes in two models of childbirth care in Brazilian private hospitals showed a lower CS rate, with no difference in neonatal outcomes, with the model of care offered by the multidisciplinary team. 30,32−35
This study’s strengths rely on the fact that all interventions were performed for medical reasons, following evidence-based protocols and guidelines; the motivation for a vaginal birth and a positive childbirth experience, both from the women and the multidisciplinary team; and the quality of the data, a great concern of these PP professionals, supported by the fact that no woman was left out of Robson’s groups classification.
Potential limitations include: its population is composed majorly of women seeking a vaginal birth and women with a higher risk for a CS or a contraindication for a vaginal birth might have been excluded; all women were from the private sector and, in this town, this represents less than half of the population; all patients were cared by a team with the same professional as a leader and, given this database was collected throughout various years, changes in the team and in the conducts were not considered, Besides, maternal and neonatal outcomes were not object of this study, as well as the evaluation of the women’s experience. Another limiting factor is the low coverage of midwives given the additional fee charged by them: this might have discouraged women who had their follow-up during the antenatal care to hire them for the birth. Low coverage of such midwifery services is described as a barrier to the implementation of collaborative care in the US. 36
This study results, although in a small population, demonstrate the real possibility of obtaining CS rates according to those displayed in WHO publications by offering multidisciplinary childbirth care that follows evidence-based protocols and proposes to provide a positive childbirth experience as recommended by the WHO. Health policies should promote health education to the population and health professionals, focusing on disseminating and implementing such practices both in the public and private sectors.