Implementing the Robson Classification for caesarean sections in Pakistan: experience, challenges, and lessons learned

The Robson Classification System is recognised as a first step for optimising the use of caesarean section and as a strategy for continuous quality improvement in maternal and newborn health. This Viewpoint provides a detailed account of the strategy adopted and lessons learned from a collaborative initiative to institutionalise the Robson Classification into Pakistan's health system. We developed a training package which emphasised capacity building of senior clinicians to act as master trainers. We also developed a mobile application for data collection and analysis. Training workshops took place in 2020 in a selection of public sector, tertiary-level, teaching hospitals from across the country and data was collected on all births in participating hospitals' obstetric units for a full year. Pakistan is poised for scale-up with the Robson Classification embedded in 57% of Pakistan's public, tertiary, teaching hospitals. A core group of master trainers is positioned in every province, and a robust dataset is available. However, integration into any health system cannot be thought of as a finite project. It requires government commitment, training and an ongoing process with built-in data quality assurance and feedback to clinicians.