Robson Classification: Implementation Manual ISBN 978-92-4-151319-7 © World Health Organization 2017 Some rights reserved. This work is available under the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 IGO licence (CC BY-NC- SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo). Third-party materials. If you wish to reuse material from this work that is attributed to a third party, such as tables, figures or images, it is your Under the terms of this licence, you may copy, redistribute and adapt the work responsibility to determine whether permission is needed for that reuse and to for non-commercial purposes, provided the work is appropriately cited, as obtain permission from the copyright holder. The risk of claims resulting from indicated below. In any use of this work, there should be no suggestion that infringement WHO endorses any specific organization, products or services. 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However, the published material is being http://apps.who.int/bookorders. To submit requests for commercial use and distributed without warranty of any kind, either expressed or implied. The queries on rights and licensing, see http://www.who.int/about/licensing. responsibility for the interpretation and use of the material lies with the reader. In no event shall WHO be liable for damages arising from its use. Table of Content 01 Introduction 3 06 The Robson Report Table 32 Purpose and target How to interpret the 02 audience of this manual 7 07 Robson Classification data 35 Barriers and Facilitators to 03 The Robson Classification 9 08 implement the Classification 48 Frequent questions on 04 how to classify women 21 09 References 50 Ways of classifying women Example of Robson Report Table with Interpretation available at: 05 in the Robson groups 28 www.who.int/reproductivehealth/publications/maternal_perinatal_health/robson-classification/en/ Introduction 01. Introduction “RISING CS RATES ARE A MAJOR PUBLIC HEALTH CONCERN” Over the last decades, there has been a progressive Traditionally, at facility level, we have monitored CS rates increase in the rate of deliveries by caesarean section (CS) using the overall percentage of deliveries by CS. in most countries but the drivers for this trend are not Variations in this “overall CS rate” between different completely understood (1, 2). Rising CS rates are a major settings or over time are difficult to interpret and compare public health concern and cause worldwide debates due because of intrinsic differences in hospital factors and to potential maternal and perinatal risks associated with infrastructure (e.g. primary versus tertiary level), this increase, inequity in access and cost issues (3-7). differences in the characteristics of the obstetric In order to understand the drivers of this trend and to population (“case-mix”) served (e.g. percent of women propose and implement effective measures to reduce or with previous CS) and differences in clinical management increase CS rates where needed, it is necessary to have a protocols (e.g. conditions for induction or pre-labour CS). tool to monitor and compare CS rates in a same setting Ideally, there should be a classification system to monitor over time and between different settings. and compare CS rates at facility level in a standardized, reliable, consistent and action-oriented manner (3, 8-10). 3 ROBSON CLASSIFICATION IMPLEMENTATION MANUAL This classification system should be Such a system should be simple, common myths about the causes for applicable internationally and it clinically relevant, accountable, increasing CS rates should also be useful for clinicians, replicable and verifiable (10, 11). as well as potential risks and benefits facility administrators, public health The lack of such an internationally- of increasing CS rates. authorities and women themselves. recognized system has helped to fuel controversies and to maintain Figure 1: Latest available data on caesarean section rates by country (from 2005 and later). From: The Increasing Trend in Caesarean Section Rates: Global, Regional and National Estimates: 1990-2014 (1). 4 ROBSON CLASSIFICATION IMPLEMENTATION MANUAL Introduction Different authors have created and proposed several types of CS Since this system can be used prospectively and its categories are classification systems for use at facility level for different totally inclusive and mutually exclusive, every woman who is purposes, with the overall aim of providing a consistent and admitted for delivery can be immediately classified, based on a standardized framework to look at CS (10). In 2011 the World few basic characteristics which are usually routinely collected by Health Organization (WHO) conducted a systematic review that obstetric care providers worldwide. identified 27 different systems to classify CS. These The classification is simple, robust, reproducible, clinically classifications looked at “who” (woman-based), “why” relevant, and prospective. It allows the comparison and analysis (indication-based), “when” (urgency-based), as well as “where”, of CS rates within and across these groups of women. Even before “how” and “by whom” a CS was performed (10). official endorsement by an international institution or formal This review concluded that women-based classifications in guidelines recommending its use in 2015, the Robson general, and the 10-Groups classification in particular (9), were in Classification had been rapidly and increasingly used by many the best position to fulfill current international and local needs. countries all over the world. In 2014 WHO conducted another The 10-Groups classification (also known as the “TGCS-Ten systematic review to gather the experience of the users of the Robson Classification, to assess the pros and cons of its adoption, Groups Classification System” or the “Robson Classification”) was created to prospectively identify well-defined, clinically implementation and interpretation, and to identify barriers, relevant groups of women admitted for delivery and to facilitators and potential adaptations (11). investigate differences in CS rates within these relatively This review included 73 publications from 31 countries that homogeneous groups of women (9). reported on the use of Robson Classification between 2000-2013. According to users, most of whom were care providers, the main Unlike classifications based on indications for CS, the Robson strengths of this classification are its simplicity, robustness, Classification is for “all women” who deliver at a specific setting reliability and flexibility (11). (e.g. a maternity or a region) and not only for the women who deliver by CS. It is a complete perinatal classification. However, users also reported that missing data, misclassification of women, and lack of definition or consensus on core variables of the classification were challenges in its implementation and use. 5 ROBSON CLASSIFICATION IMPLEMENTATION MANUAL In October 2014, WHO convened a panel of experts. After reviewing the evidence, the panel proposed the use of the Robson Classification at facility level in order to establish a common point for comparing maternal and perinatal data within facilities over time and between facilities (3, 8). The panel also decided to adopt the “Robson Classification” as the official name for this classification. WHO statement on Robson Classification “WHO proposes the Robson Classification system as a global standard for assessing, monitoring and comparing caesarean section rates within healthcare facilities over time, and between facilities”. 6 Purpose and target audience of this manual 02. Purpose and target audience of this manual “THIS MANUAL WAS CREATED