Globally, CS rates are increasing, even in groups of women who would a priori have a lower risk of requiring CS (5,25). The percentage of births that occur through CS in LAC reaches 40.5% (2). Our study shows that Uruguay is no exception to this trend, and that over the years the medicalization of childbirth has increased following the model of other LAC countries (4).
The analysis of age, parity, BMI and previous CS in this study reveals there was an increase in these potential risk factors throughout the period. The analysis by Robson groups, which allows to adjust for parity and previous CS, enabled us to rule out two potential explanations. We believe that the increase in age and BMI in women are not enough to explain the increase in CS at least in the groups at lower risk of receiving a CS. Groups 6 to 9, which include nulliparous and multiparous patients with singletons in breech or transverse presentation or twins with CS rates typically over 90% actually contribute less than 6% each in 2018. The high rates in groups 6, 7 and 9 reflect the adoption of the recommendation that emerged from the systematic review on breech labour (26,27). Yet, the evidence available (28) does not justify the high rates of CS observed in women with multiple pregnancies, including women with previous uterine scars (group 8). On the other hand, there is no justification for the significant contribution to the overall rate of groups 1, 2A, 2B, 3 and 4B for 2018, considering their low risk.
Group 5 had the highest relative contribution in 2018 and was the group with the largest increase in terms of relative contribution over the years (Table 4). This shows that the increase generated over time in the groups of nulliparas at lower risk has led to an increase in the number of patients with caesarean scar, a simple explanation of the consequent increase in the overall rate of CS, largely concentrated among women in group 5.
The results of this study are comparable with those obtained by another high-income country. A recent study in Canada found that the group with the highest contribution to the overall CS rate was group 5 (29). Our study also shows the increased representation of group 5, and while in 2018 this group accounted for approximately 20% of the obstetric population (Fig. 1), one-third of all the women undergoing a CS were in this group.
Earlier studies have reported excessive interventions in high-income countries, particularly in the private sector, calling the phenomenon “too much, too soon” (30), reflecting weak enforcement capacity and low compliance to evidence-based practices. The overuse of unnecessary CS in low-risk women cannot be associated with the improvements observed in neonatal outcomes since perinatal interventions with an impact on neonatal health have been incorporated over time. The analysis of the proportions of CS in the groups with the lowest risk of receiving a CS by sector of care, reveals differences to the detriment of women in the private sector. In the last year, these differences ranged between 14.6% and 11.1% (for groups 1 and 2 respectively). Although this study did not incorporate information prior to 2008, we see that from that year on there was a slight trend towards an increase in the number of births taking place in the private sector, a phenomenon that can be explained by the changes in the health care system, even when the overall number of births decreased slightly in the country as a whole. Considering that in the private sector the criteria for indicating CS to patients with the same obstetric risk is “laxer”, the migration of users from the public to the private sector would have increased the number of potential CS recipients.
There are multiple factors that affect and explain the high rates of CS, including economic, logistic, related to the culture of the women and their families, professionals views, organization of the health care system, and funding structures or incentives (9,31,32). The Uruguay's health system is organized in such a way that only a minority and privileged sector of clients are able to choose the doctor that will take care of their delivery, leaving the great majority of births in the hands of the obstetricians on duty. Thus, we would not anticipate financial incentives for on-call obstetricians to expedite births. Some studies have reported the lack of skills to conduct a vaginal birth (33–35), perception of CS as beneficial (33,36), the belief that women prefer a CS or the perception that women are not capable of having a vaginal birth (37–39) as reason for the high rates of CS. However, according to a recent review, only a minority of women from different countries and situations stated a preference for CS as a mode of delivery (40). Many studies have even reported that women claimed they lacked autonomy over birth-related decisions. Several women said they had initially rejected the option of a CS, only to be eventually convinced to undergo CS by the doctor in charge at the time (41–46). In Uruguay, it would be important to review and strengthen the implementation of existing clinical guidelines on the management of induction of labor and scheduling of caesarean delivery. In addition, the provision of comprehensive health education and counseling during antenatal care should be a priority, as recommended by WHO (47).
Strengths and limitations
Our analysis has some limitations. Due to SIP coding constraints, we were unable to discriminate clients covered by private health insurance who account for about 3%, of the total number. It is likely that some differences observed in the private sector will further deepen in this population.
This is the first trend analysis in Uruguay at national level using the Robson classification with high coverage of birth due to the well-established SIP as a standard for data collection during pregnancy and birth. Thanks to the nationwide implementation of the system, combined with the universalization of institutional childbirth it is possible to obtain national indicators by subsectors and geographies comparable over time; this is highly beneficial for clinical practice, research, audits, management and evaluation of health care services. This software allows to alert about situations that differ from what would be expected, so as to anticipate the risk of CS, and obtain indicators by Robson groups in real time. The monitoring of CS rates by Robson groups is a strategy that allows health decisions to be made, ensuring the comparability of information. It is important to allocate human and budgetary resources to maintain and improve the systematization and entry of registries into the system, to allow the continuity of epidemiological surveillance of perinatal and maternal health in the countries of the region.