352 Bull Wo ld Heal h O gan 2022;100:352–354 | doi: h p://dx.doi.o g/10.2471/BLT.21.287742
Pe spec i es
Op imizing caesa ean sec ion use is a
global heal h p io i y, gi en he ma e nal
and pe ina al mo bidi y and mo ali y
associa ed wi h caesa ean unde use and
o e use.1,2 Moni o ing caesa ean sec-
ion a es is impo an o unde s and
ends, iden i y inequi ies in hei use,
and de elop and implemen s a egies
o op imize hei use. Howe e , he lack
o an in e na ionally accep ed classi ica-
ion sys em has hinde ed ou ine global
moni o ing o caesa ean sec ion a es. In
addi ion, moni o ing o e all agg ega e
caesa ean sec ion a es is no su icien .
Fine disagg ega ed da a a e needed o
cha ac e ize and pinpoin obs e ic sub-
g oups d i ing caesa ean sec ion a es
and o suppo app op ia e in e en ion
a ge ed a he app op ia e g oups which
mos con ibu e o he o e all caesa ean
sec ion a e.
In 2015, he Wo ld Heal h O ga-
niza ion (WHO) ecommended he
10-g oup classi ica ion sys em: he Rob-
son classi ica ion, as a global s anda d
o assessing, moni o ing and compa -
ing caesa ean sec ion a es wi hin and
be ween ma e ni y uni s wo ldwide.3
The sys em classi ies all women a ad-
mission o bi h in o 10 g oups based
on basic obs e ic cha ac e is ics ha
a e ou inely collec ed in ma e ni y
uni s wo ldwide (pa i y and p e ious
caesa ean sec ions, numbe o e uses,
ges a ional age, e al p esen a ion and
lie, and onse o labou ). The s uc u e
o he classi ica ion allows use s o be e
analyse and unde s and labou e en s,
clinical p ac ices, indica ions, ou comes
and signi ican epidemiological ac o s
including case mix. The classi ica ion
se es as a common language necessa y
o b ing heal h p ac i ione s oge he
in a cons uc i e deba e abou clinical
p ac ices in ela ion o caesa ean sec-
ions. A 2018 sys ema ic e iew o six
s udies showed ha implemen a ion
o he Robson classi ica ion may be
associa ed wi h educed caesa ean sec-
ion a es.4
The Robson classi ica ion has gained
wide accep ance in a di e se ange o
heal h-ca e, esea ch and policy-making
se ings wo ldwide,5,6 and i s widesp ead
adop ion p esen s an oppo uni y o
moni o and compa e caesa ean sec ion
a es and pe ina al ou comes on a much
la ge scale using a simila and s anda d
me hod. In 2017, o assis heal h-ca e a-
cili ies in adop ing and using he Robson
classi ica ion, WHO de eloped guidance
o i s use, implemen a ion and in e p e-
a ion, including s anda diza ion o e ms
and de ini ions.7
WHO announces ano he ool o
acili a e he use o he Robson clas-
si ica ion, he Robson pla o m.8 This
global, ee, in e ac i e pla o m is a
place whe e indi idual ma e ni y uni s
wo ldwide can upload and sha e hei
hospi al-le el caesa ean and associ-
a ed pe ina al ou come da a using he
Robson classi ica ion sys em. The da a
a e a ailable openly and upda ed in
eal ime as soon as acili ies upload
new da a.
The da a om he pla o m can be
used o mul iple pu poses: (i) moni o -
ing and compa ing ends o caesa ean
sec ion a es and associa ed ou comes
ac oss di e en se ings; (ii) iden i ica-
ion o g oups o women which mos
con ibu e o o e all caesa ean sec ion
a es; (iii) e alua ion o policies and
in e en ions o op imize caesa ean sec-
ion use; (i ) assessmen o he quali y
o ca e and obs e ic p ac ices by ana-
lysing ou comes ac oss di e se se ings;
and ( ) assessmen o he quali y o
obs e ic da a including he p opo ion
o unclassi ied women due o missing
in o ma ion.7
The pla o m p o ides easy access o
da a on caesa ean sec ion a es and as-
socia ed pe ina al ou comes and clinical
p ocesses in ma e ni y uni s wo ldwide
in he s anda d o ma o he Robson
classi ica ion, allowing moni o ing and
compa ison o caesa ean sec ion a es
ac oss ma e ni y uni s and coun ies,
and o e ime. The pla o m also allows
use s o c ea e cus omized cha s and
g aphs o isualize caesa ean sec ion
da a quickly and e o lessly a speci ic
ime poin s, o o e ime o he whole
obs e ic popula ion o pe indi idual
Robson g oups (Fig. 1 and Fig. 2). This
ea u e o he pla o m allows use s om
di e en ma e ni y uni s a ound he
globe o engage in da a-d i en discus-
sions and sha e expe iences and clini-
cal p o ocols o p ac ices ha may be
ele an o op imize caesa ean sec ion
use and ou comes.
In he Robson pla o m, use s can
iew caesa ean sec ion a es o each
heal h acili y acco ding o speci ic
c i e ia o in e es ( o example, yea
o Robson g oup). Use s will also be
able o sha e da a on clinical p ocesses
(such as de ini ions o spon aneous
labou , induced labou and bi h) ha
will enable a deepe unde s anding o
di e ences in caesa ean sec ions and
pe ina al ou comes ac oss ma e ni y
uni s. The pla o m is dynamic and will
unde go con inuous imp o emen , wi h
addi ional ea u es added acco ding o
use needs and eedback.
WHO’s Robson pla o m o da a-sha ing on caesa ean sec ion a es
New on Opiyo,a Ma ia Regina To loni,b Michael Robson,c La s Lad o s,d Ka ima Gholbzou i,e
Jus ina Kace auskiene, Ra ael Vila-Candel,g Joe g Kessle ,h Miha Luco niki & Ana Pila Be ána
a UNDP/UNFPA/UNICEF/WHO/Wo ld Bank Special P og amme o Resea ch, De elopmen and Resea ch T aining in Human Rep oduc ion (HRP), Depa men o
Rep oduc i e Heal h and Resea ch, Wo ld Heal h O ganiza ion, A enue Appia 20, 1211 Gene a 27, Swi ze land.
b E idence Based Heal hca e Pos g adua e P og am, São Paulo Fede al Uni e si y, São Paulo, B azil.
c Na ional Ma e ni y Hospi al, Dublin, I eland.
d Depa men o Obs e ics and Gynaecology, Sahlg enska Uni e si y Hospi al, Go henbu g, Sweden.
e Depa men o Heal h P omo ion, Wo ld Heal h O ganiza ion Regional O ice o he Eas e n Medi e anean, Cai o, Egyp .
Li huanian Uni e si y o Heal h Sciences, Kaunas, Li huania.
g Hospi al de La Ribe a, Valencia, Spain.
h Depa men o Obs e ics and Gynaecology, Haukeland Uni e si y Hospi al, Be gen, No way.
i Depa men o Pe ina ology, Uni e si y Medical Cen e Ljubljana, Ljubljana, Slo enia.
Co espondence o New on Opiyo (email: opiyon@ who .in ).
(Submi ed: 23 Decembe 2021 – Re ised e sion ecei ed: 4 Ma ch 2022 – Accep ed: 9 Ma ch 2022 – Published online: 4 Ap il 2022 )
Pe spec i es
353
Bull Wo ld Heal h O gan 2022;100:352–354| doi: h p://dx.doi.o g/10.2471/BLT.21.287742
Pe spec i es
WHO’s Robson pla o m o da a-sha ing on caesa ean sec ion a es
New on Opiyo e al.
When assessing and in e p e ing
caesa ean sec ion a es and pe ina al
ou comes using he Robson classi ica-
ion, use s a e encou aged o conside
o he ac o s ha a e no p o ided in
he pla o m bu can ha e a signi ican
impac on esul s. Heal h-sys em ac o s
(models o ca e, paymen sys ems o
heal h p o ide s and acili ies, s a ing
o esou ce a ailabili y) and clinical
p ocesses ha a y be ween ma e ni y
uni s (diagnosis o labou , e al dis ess,
managemen o dys ocia, elec onic e al
moni o ing o indica ions o caesa ean
sec ion) may impac caesa ean sec ion
a es and ou comes.9
The pla o m can help o s anda d-
ize ou ine audi o caesa ean sec ion
a es and ou comes, simpli y com-
pa isons and quickly iden i y obs e ic
subg oups d i ing caesa ean sec ion
a es. Enhanced unde s anding o he
d i e s o caesa ean sec ion ends can
help use s o de elop mo e ailo ed and
e ec i e in e en ions o hei se ing.
Embedding he Robson classi ica ion
sys em in o ou ine ma e ni y da a col-
lec ion can mo i a e acili ies o imp o e
he quali y o hei obs e ic da a.
Caesa ean sec ion use is inc easing
wo ldwide; i s use is unequal in low- and
middle-income coun ies, and i s unde -
use and o e use is associa ed wi h ad e se
ou comes. The e o e, using ools such as
he Robson classi ica ion sys em is a p i-
o i y o he heal h communi y. We hope
ha he pla o m will help build e idence
o in o m ailo ed, da a-d i en policies
and ac ions o op imize caesa ean use. ■
Funding: The Uni ed Na ions De elop-
men Fund, Uni ed Na ions Popula ion
Fund, Uni ed Na ions Child en’s Fund,
he Wo ld Heal h O ganiza ion and
he Wo ld Bank Special P og amme o
Resea ch, De elopmen and Resea ch
T aining in Human Rep oduc ion ha e
unded he Robson pla o m.
Compe ing in e es s: None decla ed.
Fig. 1. Caesa ean sec ion a es by Robson classi ica ion, he Na ional Ma e ni y
Hospi al, I eland, 2020
G oup 1G oup 2G oup 3G oup 4G oup 5G oup 6G oup 7G oup 8G oup 9G oup 10
%
100
90
80
70
60
50
40
30
20
10
0
Robson classi ica ion g oup
G oup size Caesa ean sec ion a e Absolu e g oup con ibu ion
Rela i e g oup con ibu ion
No es: The sys em classi ies all women a admission o bi h in o 10 g oups based on basic obs e ic
cha ac e is ics (pa i y and p e ious caesa ean sec ions, numbe o e uses, ges a ional age, e al
p esen a ion and lie, and onse o labou ). G oup size is numbe o women in he g oup / o al numbe
o women deli e ed in he se ing x 100. Caesa ean sec ion a e is numbe o caesa ean sec ions in he
g oup / o al numbe o women in he g oup x 100. Absolu e g oup con ibu ion is numbe o caesa ean
sec ions in he g oup / o al numbe o women deli e ed in he se ing x 100. Rela i e g oup con ibu ion
is numbe o caesa ean sec ions in he g oup / o al numbe o caesa ean sec ions in he se ing x 100.
Fig. 2. T ends in caesa ean sec ion a es by Robson g oup, he Na ional Ma e ni y Hospi al, I eland, 2007–2020
2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020
%
100
90
80
70
60
50
40
30
20
10
0
Yea
G oup 1 G oup 2
G oup 3 G oup 4 G oup 5 G oup 6 G oup 7 G oup 8 G oup 9 G oup 10
No es: The sys em classi ies all women a admission o bi h in o 10 g oups based on basic obs e ic cha ac e is ics ha a e ou inely collec ed in ma e ni y uni s
wo ldwide (pa i y and p e ious caesa ean sec ions, numbe o e uses, ges a ional age, e al p esen a ion and lie, and onse o labou ). Some cau ion is needed
in in e p e ing hese changes wi hou knowing how he sizes o he g oups ha e changed o e he same pe iod. In addi ion, o he pe ina al ou comes need o
be included as well as signi ican epidemiological a iables in he index popula ion. The inal in e p e a ion o caesa ean sec ion a es can only be made when all
hese ac o s a e included.
354 Bull Wo ld Heal h O gan 2022;100:352–354| doi: h p://dx.doi.o g/10.2471/BLT.21.287742
Pe spec i es
WHO’s Robson pla o m o da a-sha ing on caesa ean sec ion a es New on Opiyo e al.
Re e ences
1. Sandall J, T ibe RM, A e y L, Mola G, Visse GH, Home CS, e al. Sho - e m
and long- e m e ec s o caesa ean sec ion on he heal h o women and
child en. Lance . 2018 Oc 13;392(10155):1349–57. doi: h p:// dx .doi .o g/ 10
.1016/ S0140 -6736(18)31930 -5 PMID: 30322585
2. Sobhy S, A oyo-Manzano D, Mu ugesu N, Ka hikeyan G, Kuma
V, Kau I, e al. Ma e nal and pe ina al mo ali y and complica ions
associa ed wi h caesa ean sec ion in low-income and middle-income
coun ies: a sys ema ic e iew and me a-analysis. Lance . 2019
May 11;393(10184):1973–82. doi: h p:// dx .doi .o g/ 10 .1016/ S0140
-6736(18)32386 -9 PMID: 30929893
3. WHO s a emen on caesa ean sec ion a es. Gene a: Wo ld Heal h
O ganiza ion; 2015. A ailable om: h ps:// apps .who .in / i is/ bi s eam/
handle/ 10665/ 161442/ WHO _RHR _15 .02 _eng .pd [ci ed 2021 Dec 17].
4. Boa in AA, Cullinane F, To loni MR, Be án AP. Audi and eedback using he
Robson classi ica ion o educe caesa ean sec ion a es: a sys ema ic e iew.
BJOG. 2018 Jan;125(1):36–42. doi: h p:// dx .doi .o g/ 10 .1111/ 1471 -0528
.14774 PMID: 28602031
5. Be án AP, Vinde oghel N, Souza JP, Gülmezoglu AM, To loni MR. A
sys ema ic e iew o he Robson classi ica ion o caesa ean sec ion:
wha wo ks, doesn’ wo k and how o imp o e i . PLoS One. 2014 Jun
3;9(6):e97769. doi: h p:// dx .doi .o g/ 10 .1371/ jou nal .pone .0097769 PMID:
24892928
6. To loni MR, Be an AP, Souza JP, Widme M, Allen T, Gulmezoglu M, e al.
Classi ica ions o cesa ean sec ion: a sys ema ic e iew. PLoS One. 2011 Jan
20;6(1):e14566. doi: h p:// dx .doi .o g/ 10 .1371/ jou nal .pone .0014566 PMID:
21283801
7. Robson classi ica ion. Implemen a ion manual. Gene a: Wo ld Heal h
O ganiza ion; 2017. A ailable om: h p:// apps .who .in / i is/ bi s eam/
10665/ 259512/ 1/ 9789241513197 -eng .pd [ci ed 2021 Dec 17].
8. WHO Robson classi ica ion pla o m. Gene a: Wo ld Heal h O ganiza ion;
2021. A ailable om: h ps:// obson -classi ica ion -pla o m .s h .o g/ [ci ed
2022 Ma 16].
9. Robson MS. Can we educe he caesa ean sec ion a e? Bes P ac Res Clin
Obs e Gynaecol. 2001 Feb;15(1):179–94. doi: h p:// dx .doi .o g/ 10 .1053/
beog .2000 .0156 PMID: 11359322
Co igendum
In: Hea h, K., Alonso, M., Aguila , G., Samudio, T., Ko en omp, E., e al. WHO me hod o es ima ing congeni al syphilis o in o m su eillance
and se ice p o ision, Pa aguay. Bull Wo ld Heal h O gan. 2022 Ma 1; 100(3):231–236,
On pages 231, 234-236, he abs ac and i s ansla ed e sions should ead as ollows:
Abs ac
WHO me hod o es ima ing congeni al syphilis o in o m su eillance and se ice p o ision, Pa aguay
P oblem In Pa aguay, incomple e su eillance da a esul ed in he bu den o congeni al syphilis being unde es ima ed, which, in u n, led
o missed oppo uni ies o in an diagnosis and ea men .
App oach The incidence o congeni al syphilis, as de ined by he Wo ld Heal h O ganiza ion (WHO), was es ima ed o Pa aguay using he
WHO congeni al syphilis es ima ion ool. This ool was also used o moni o p og ess owa ds he elimina ion o mo he - o-child ansmission
o syphilis.
Local se ing The bu den o syphilis in Pa aguay has his o ically been high: i s p e alence in p egnan women was es ima ed o be 3% in 2018.
Rele an changes The incidence a e o congeni al syphilis es ima ed using he WHO ool was a ound nine imes he epo ed incidence.
Subsequen ly, Pa aguay: (i) p o ided aining o imp o e diagnosis and case epo ing; (ii) s eng hened in o ma ion sys ems o case moni o ing
and epo ing; and (iii) p ocu ed addi ional apid dual HIV–syphilis and apid plasma eagin es s o inc ease syphilis es ing capaci y. In addi ion,
he Minis y o Heal h p epa ed a new na ional plan o elimina ing mo he - o-child ansmission o syphilis, wi h clea moni o ing miles ones.
Lessons lea n Heal h-ca e p o ide s’ epo ing and su eillance p ocedu es o congeni al syphilis may no adequa ely e lec na ional and
in e na ional case de ini ions. Use o he WHO congeni al syphilis es ima ion ool in Pa aguay d ew a en ion o congeni al syphilis as a na ional public
heal h p oblem and highligh ed he impo ance o comp ehensi e na ional su eillance sys ems and accu a e da a. Ongoing use o he WHO ool can
ack p og ess owa ds he elimina ion o mo he - o-child ansmission o syphilis by helping imp o e syphilis se ice co e age and na ional su eillance.
صخلم
ياوغاراب ،تامدلخا ميدقتو ةبقارلما ضرغب يقللخا يرهزلا مييقتل ةيلماعلا ةحصلا ةمظنم ةقيرط
دلحا لىإ ياوغاراب في ةلمتكلما يرغ ةبقارلما تانايب تدأ ةلكشلما
صرف عايض لىإ هرودب ىدأ امم ،يقللخا يرهزلا مييقت ءبع نم
.مهجلاعو عضرلا صيخشت
اًقفو ،يقللخا يرهزلا ضرمب ةباصلإا مييقت مت بولسلأا
مادختساب ياوغاراب في ،(WHO) ةيلماعلا ةحصلا ةمظنم فيرعتل
مت .ةيلماعلا ةحصلا ةمظنلم ةعباتلا يقللخا يرهزلا مييقت ةادأ
لاقتنا لىع ءاضقلا وحن مدقتلا دصرل ا ً
ضيأ ةادلأا هذه مادختسا
.لفطلا لىإ ملأا نم يرهزلا ضرم
لىع اًعفترم ياوغاراب في يرهزلا ضرم ءبع ناك ةيلحلما عقاولما
ةبسنب لماولحا ءاسنلا ينب هراشتنا ريدقت مت دقف ،اهيخرات ىدم
.2018 ماع في 3%
يرهزلا ضرمب ةباصلإا لدعم ناك ةلصلا تاذ تا ّ
يرغتلا
،ةيلماعلا ةحصلا ةمظنم ةادأ مادختساب همييقت مت يذلا ،يقللخا
تماق دقف لياتلابو .اهنع غلبُلما ةباصلإا فاعضأ ةعست لياوح
صيخشتلا ينسحتل بيردتلا يرفوت (1) :ليي ماب ياوغاراب
دصرل تامولعلما مظن زيزعت (2)و ؛تلاالحا نع غلابلإاو
ةعيسر ةيفاضإ تارابتخا ءاشر (3)و ؛اهنع غلابلإاو تلاالحا
تارابتخاو ،يرهزلاو ةيشربلا ةعانلما صقن سويرفل ةجودزم
ةفاضلإابو .يرهزلا رابتخا لىع ةردقلا ةدايزل ةعيسرلا امزلابلا
ءاضقلل ةديدج ةينطو ةطخ ةحصلا ةرازو تدعأ دقف ،كلذ لىإ
ةبقارم لحارم عم ،لفطلا لىإ ملأا نم يرهزلا ضرم لاقتنا لىع
.ةحضاو
