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Implementation of the WHO Manual for Robson Classification: an Example from Sri Lanka Using a Local Database for Developing Quality Improvement Recommendations

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Implementation of the WHO Manual for Robson Classification: an Example from Sri Lanka Using a Local Database for Developing Quality Improvement Recommendations Open access Research BMJ Open: first published as 10.1136/bmjopen-2018-027317 on 8 February 2019. Downloaded from Implementation of the WHO manual for Robson classification: an example from Sri Lanka using a local database for developing quality improvement recommendations Hemantha Senanayake,1,2 Monica Piccoli,3 Emanuelle Pessa Valente, 3 Caterina Businelli,3 Rishard Mohamed,1,2 Roshini Fernando,2 Anshumalie Sakalasuriya,2 Fathima Reshma Ihsan,2 Benedetta Covi,3 Humphrey Wanzira,3 Marzia Lazzerini3 To cite: Senanayake H, ABSTRACT Strengths and limitations of this study Piccoli M, Valente EP, et al. Objectives This study aimed at describing the use of a Implementation of the prospective database on hospital deliveries for analysing ► Despite being a single-centre study, this is the first WHO manual for Robson caesarean section (CS) practices according to the WHO classification: an example study from a setting with limited resources reporting manual for Robson classification, and for developing from Sri Lanka using a local on the use of a prospective individual-patient data- recommendations for improving the quality of care database for developing base for analysing practices on caesarean section. (QoC). quality improvement ► This is also the first report on the use of the WHO Design Observational study. recommendations. BMJ Open implementation manual for Robson classification in Setting University Obstetric Unit at De Soysa Hospital for 2019;9:e027317. doi:10.1136/ a project aiming at quality improvement. The paper bmjopen-2018-027317 Women, the largest maternity unit in Sri Lanka. describes how the WHO manual can be used in an Data collection and analysis For each childbirth, 150 ► Prepublication history and action-oriented manner for developing recommen- variables were routinely collected in a standardised additional material for this dations for improving the quality of maternal health- form and entered into a database. Data were routinely paper are available online. To care, and the quality of data collected. view these files, please visit monitored for ensuring quality. Information on deliveries http://bmjopen.bmj.com/ ► This pilot experience can be of interest to both re- occurring from July 2015 to June 2017 were analysed the journal online (http:// dx. doi. searchers and policy makers, providing a model org/ 10. 1136/ bmjopen- 2018- according the WHO Robson classification manual. Findings on how different types of variables can inform the 027317). were discussed internally to develop quality improvement Robson classification, and how findings from the recommendations. Robson classification can be used proactively for Received 16 October 2018 Results 7504 women delivered in the hospital during Revised 17 December 2018 decision making. the study period and at least one maternal or fetal Accepted 20 December 2018 pathological condition was reported in 2845 (37.9%). The CS rate was 30.0%, with 11.9% CS being performed prelabour. According to the Robson classification, Group INTRODUCTIOn on September 27, 2021 by guest. Protected copyright. 3 and Group 1 were the most represented groups (27.0% Improving the appropriate use of caesarean and 23.1% of population, respectively). The major section (CS) is a major global concern.1 2 contributors to the CS rate were group 5 (29.6%), group While global CS rates at the population level 1 (14.0%), group 2a (13.3%) and group 10 (11.5%). The are rising, major disparities exist among most commonly reported indications for CS included countries, with both underuse and overuse abnormal cardiotocography/suspected fetal distress, past 1 2 CS and failed progress of labour or failed induction. These of this procedure. Although there is no suggested the need for further discussion on CS practices. debate about the need to increase access to © Author(s) (or their Overall, 18 recommendations were agreed on. Besides safe CS, there is also common agreement that employer(s)) 2019. Re-use updating protocols and hands-on training, activities agreed CS should be performed only for medically permitted under CC BY-NC. No 1 2 commercial re-use. See rights on included monitoring and supervision, criterion-based indicated reasons. and permissions. Published by audits, risk management meetings and appropriate Interventions to reduce unnecessary CS BMJ. information for patients, and recommendations to further have shown little success.2 In the last few For numbered affiliations see improve the quality of data. years, WHO has endorsed the use of the end of article. Conclusions This study provides an example on how the Robson classification system,3 and a manual WHO manual for Robson classification can be used in an for supporting its implementation was Correspondence to action-oriented manner for developing recommendations published in 2017.4 The WHO Robson clas- Dr Marzia Lazzerini; for improving the QoC, and the quality of data collected. marzia. lazzerini@ burlo. trieste. it sification manual guides the implementation Senanayake H, et al. BMJ Open 2019;9:e027317. doi:10.1136/bmjopen-2018-027317 1 Open access BMJ Open: first published as 10.1136/bmjopen-2018-027317 on 8 February 2019. Downloaded from of the Robson classification and provides practical tools Box 1 The 10 groups of the Robson classification4 for analysing CS practice in a standardised, reliable, 4 consistent and action-oriented manner. However, there Group 1: Nulliparous women with a single cephalic pregnancy, is still little published experience on the practical utilisa- ≥37 weeks gestation in spontaneous labour 4 tion of the WHO Robson classification manual, and no Group 2: Nulliparous women with a single cephalic pregnancy, concrete experience has been reported so far on how to ≥37 weeks gestation who had labour induced or were delivered by cae- use the manual in an action-oriented manner. sarean section (CS) before labour A rising trend in the national CS rate has been reported 2a Labour induced in Sri Lanka (33.2% in 2015), with large heterogeneity 2b Prelabour CS among different facilities5 6 and widespread diffusion Group 3: Multiparous women without a previous CS, with a single ce- of inappropriate indications for CS.7 Nevertheless, few phalic pregnancy, ≥37 weeks gestation in spontaneous labour Group 4: Multiparous women without a previous CS, with a single ce- studies have analysed CS practices in a standardised 7 8 phalic pregnancy, ≥37 weeks gestation who had labour induced or were manner and no study used findings of such analyses for delivered by CS before labour developing recommendations to improve the quality of 4a Labour induced maternal healthcare and the quality of data collected. 4b Prelabour CS Since year 2015 we implemented a prospective indi- Group 5: All multiparous women with at least one previous CS, with a vidual patient database at the De Soysa Hospital for single cephalic pregnancy, ≥37 weeks gestation Women, Colombo, the largest maternity hospital in Sri Group 6: All nulliparous women with a single breech pregnancy Lanka. For each case of delivery, about 150 variables were Group 7: All multiparous women with a single breech pregnancy includ- collected and routinely entered in an electronic data- ing women with previous CS(s) base.9 The objective of this study was to describe the use Group 8: All women with multiple pregnancies including women with of the information provided by this database to analyse previous CS(s) Group 9: All women with a single pregnancy with a transverse or oblique CS practices according to the WHO Robson classification 4 lie, including women with previous CS(s) manual in an action-oriented manner, with the aim of Group 10: All women with a single cephalic pregnancy <37 weeks ges- developing recommendations for improving the quality tation, including women with previous CS(s) of maternal hospital care. METHODS synthesised according to the standardised reporting Study design tables provided by the manual (online supplementary The study was designed as an observational study aimed tables 2–4).4 According to the WHO methodology,4 at analysing practices related to CS, and at developing the analysis should follow the following key steps. First, recommendations for improving the quality of hospital each case of birth was classified into one of the Robson care. The results section of this paper reports the findings groups (box 1), using six key variables (parity, previous http://bmjopen.bmj.com/ of the Robson analysis4 and how such findings were inter- CS, onset of labour, number of fetuses, gestational age, nally discussed and used. fetal lie presentation). Second, data were assessed for: (1) Quality. (2) Type of population. (3) CS rates. As recom- Population and setting mended in the WHO Manual,4 relevant additional infor- The study was conducted at the University Obstetric Unit 9 mation provided by the local data collection system was of De Soysa Hospital for Women, the largest maternity used as complementary information to allow an in-depth unit in Sri Lanka. Detailed methods of data collection 9 interpretation of CS practices. Specifically, the following have been previously reported. Briefly, 150 variables (ie, on September 27, 2021 by guest. Protected copyright. types of variables collected by the local individual-pa- maternal sociodemographic characteristics, risk factors, tient database were used: maternal age, gestational age, process indicators, maternal and neonatal outcomes) maternal pathological conditions (eg, diabetes, hyperten- were collected for each individual birth using
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