Towards a scalable and sustainable solution for the rising trend of caesarean section rates in Sri Lanka, Dr Chandana Jayasundara

The caesarean section rates have been steadily increasing throughout the world including Sri Lanka. unnecessary caesarean sections can result in increased maternal morbidity and mortality and is also a huge burden to the annual health budget of the developing countries. categorizing caesarean section can result in better understanding the reasons behind these unnecessary caesarean sections. WHO has recommended the Robsons 10 group classification for this purpose. collecting data delivery data according to Robsons 10 group classification using paper based data collection tools is a time consuming and cumbersome task. this oration is about the development of a web based android app (Robsapp) which can collect and analyze the delivery data according to Robsons classification. This app also can be modified to incorporate other variables that need to be analyzed in Obstetric care.

1. Sri Lanka College of Obstetricians & Gynaecologists DR J Nalin Rodrigo Memorial Oration 2022 20 th November 2022 1

2. Dr. J. Nalin Rodrigo M.B.B.S. (Cey), D. Obst. (Cey), F.C.S. (SL) F.R.C.O.G. (Gt. Britain), F.C.O.G. (SL) Hon F.C.G.P (SL), F.A.O.C.O.G. 2

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4. Late Prof. Joseph Lionel Christie Rodrigo 4

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11. Towards a scalable and sustainable solution for the rising trend of caesarean section rates in Sri Lanka. Dr Chandana Jayasundara Senior lecturer in Obstetrics and Gynaecology Faculty of Medicine, University of Colombo Honorary Consultant Obstetrician and Gynaecologist De Soysa Hospital for Women, Colombo 11

12. Introduction to caesarean section Caesarean section can be defined as delivery of the fetus from the maternal uterus through an incision in the abdomen of the mother . It is undoubtedly , the commonest major surgery in obstetrics and gynecology. 12

13. The history of caesarean section Caesarean section has been described since ancient times There is evidence of this procedure in western as well non western literature 13

14. Did the word Caesarean came from the name of the famous emperor Julius Caesar ? Aurelia Cotta:- mother of Julius Caeser 14

15. During the times of Julius Caesar, CS was performed to deliver the child of a dead or dying mother. It was common cultural practice to remove the fetus from the mother before the burial of the mother. The Term “Caesarean” may refer to patients been cut open in Latin as the Latin verb “ cae dare” means to cut 15

16. In late 19 th century this surgery became an established part in obstetric practice. This reflected the gradual transition of childbirth from a mid-wife attended and often a rural event to an urban and an institutional experience . CS was preferred over destructive procedures to deliver obstructed fetus. Later it was preferred over difficult forceps delivery which carried high morbidity 16

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18. Evolving safety of Caesarean section Internal suturing of the uterus using the silver wire suturing method Marion Simms 1813-1883 Popularizing the Pfannenstiel incision and lower segment caesarean section John Martin Munro Kerr 1868-1960 Introduction of penicillin and later widespread use of antibiotics Sir Alexander Fleming 1881-1955 Using spinal anaesthesia for CS August Bier (1861–1949) 18

19. Caesarean section: A life saving surgery Over time has evolved into a very important life-saving surgical procedure in obstetrics practice CS is done for many indications which can be broadly divided into 3 main categories Maternal fetal indications Fetal indications Maternal indications 19

20. Fetal maternal indications These are Indications that pose a threat to mother as well as the fetus Placental abruption Placenta previa , Placenta acreta , increta , percreta complications Labour dystocia 20

21. Fetal indications There are indications that poses a risk to fetus Non-reassuring fetal heart rate traces Fetal malpresentations Fetal growth restriction Maternal vaginal infections Some fetal malformations 21

22. Maternal indications These are indications that poses a risk to the mother where vaginal delivery is contraindicated. Maternal cardiac conditions Maternal CNS conditions like paralysis and stroke 22

23. Complications of caesarean delivery CD is a major surgery with immediate and long term complications Intraoperative complication Post operative complications Long term complications 23

24. Intraoperative complications U terine lacerations B ladder injury U reteral injury B owel injuries U terine atony These complications are more common when CD is performed as an emergency procedure or as a repeated procedure 24

25. Post operative complications Endometritis Sepsis W ound infection T hromboembolic disease 25

26. Long term complications Placental complications Placenta previa , accrete, increta Pfannenstiel scar defect causing incisional hernia Caesarean scar ectopic Pelvic adhesions 26

27. Trial of labour after caesarean delivery (TOLAC) TOLAC carries a risk of uterine rupture. Fetal complication and severe hypoxic brain injury Maternal complications like haemorrhage, hysterectomy and even death Thus once caesarean section performed there is higher chance for her to select repeat caesarean section in subsequent pregnancies Stresses the importance of keeping the primary CD rate low. 27

28. Caesarean delivery: the rates are rising The CD rates have been steadily rising through the world since 1950s Initially seen in the developed world Now a global problem identified by the WHO Some L atin American countries have a CD rates of 80%!!!! 28

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30. The global rising CD rate The rates as well as indications for CD vary widely throughout the world The reasons for the rise need to be studied separately for each country and each unit Caesarean Delivery rate beyond a certain level will not improve neonatal or maternal morbidity and motility The WHO has recommended a safe rate for Caesarean Delivery in a country to be below 10%-15%. This may not be suited for all settings 30

31. The perfect storm Verity of reasons have resulted in CD rates increasing out of hand H igh expectations of favorable outcome Obstetricians fear of legal implications Personnel choice on mode of delivery Convenience and financial benefit to the obstetricians More high risk pregnancies with advanced maternal age and medical complications 31

32. Individual CD rates depend on many factors nationally and internationally Social Medical Population diversity So, ideal rate for each country and each unit need to be decided by studying the individual population catered by different units around the world 32

33. The situation in Sri Lanka There is growing evidence of the rise in trend of CD in Sri Lanka According to the available national database overall CD rate in Sri Lanka has been rising from 32% in 2014 to 40.8% in 2018 () There is a large heterogeneity in the reported CD rates in different institutions in Sri Lanka. It is forecasted that more than half of all the deliveries will occur by CS in Sri Lanka by the year 2025 * * Gunawardane D, Rowel D, Dharmaratne S. The Increasing Trend in Caesarean Section Rate: Sri Lankan scenario: 2005 - 2016. In: 131st Anniversary International Medical Congress of Sri Lanka Medical Association. Colombo; 2018. 33

34. Not all CD are equal CD is a very safe and life saving surgery in most circumstances This is true when you consider a primary CD done electively in a woman with no previous surgeries or pelvic complications But when complicated by distorted anatomy or more importantly when done as an emergency procedure, complications rise disproportionately as high as 200 times!!!! Hence not all CD are equal and selecting how and what to reduce is essential 34

35. The need for a robust classification system for CD To identify reasons behind all CDs there need to be an accurate data collection and data interpretation methods in place To collect data accurately there should be a simple but robust classification system to classify each and every CD There is a timely need for a globally accepted classification system encompassing all the CDs. 35

36. Different classification systems for CD Classification system Advantages Disadvantages Categorizing CD as Emergency and Elective Can be used in data collection and Audit totally inadequate for both scientific analysis as well as recommending actions to be implemented categorizing CD 1-4 Ideal for service provision audits and team communications Unable to perform a scientific analysis and recommending actions to be implemented In fact, 2011, WHO conducted a systematic review which identified 27 different systems to classify CD * We have to select a classification system that will fulfill many requirements and be practical * Betran AP, Torloni MR, Zhang JJ, Gülmezoglu AM; WHO Working Group on Caesarean Section. WHO Statement on Caesarean Section Rates. BJOG. 2016 Apr;123(5):667-70. doi : 10.1111/1471-0528.13526. Epub 2015 Jul 22. PMID: 26681211; PMCID: PMC5034743. 36

37. Why Robsons 10 group classification ? The Robsons Classification was identified as a simple but robust, reproducible and clinically relevant classification . It is prospective classification system that will enhance the quality of data collected Robsons data can be used to compare CD rates of different indications between different units and different hospitals as well . E nable to audit and compare CD rates with the WHO recommended CD rates and to propose service improvements Endorsed by the WHO as the most suited classification system to categorize CD globally 37

38. Robson classification group number Characteristics of the group 1 Nulliparous women with single cephalic pregnancy,  37 weeks gestation in spontaneous labour 2 Nulliparous women with a single cephalic pregnancy, ≥37 weeks gestation who had labour induced or were delivered by CS before labour 2a Labour induced 2b Pre-labour CS 3 Multiparous women without a previous CS, with a single cephalic pregnancy, ≥37 weeks gestation in spontaneous labour 4 Multiparous women without a previous CS, with a single cephalic pregnancy, ≥37 weeks gestation who had labour induced or were delivered by CS before labour 4a Labour induced 4b Pre-labour CS 5 All multiparous women with at least one previous CS, with a single cephalic pregnancy, ≥37 weeks gestation 5a With one previous CS 5b With two or more previous CSs 6 All nulliparous women with a single breech pregnancy 7 All multiparous women with a single breech pregnancy including women with previous CS(s) 8 All women with multiple pregnancies including women with previous CS(s) 9 All women with a single pregnancy with a transverse or oblique lie, including women with previous CS(s) 10 All women with a single cephalic pregnancy < 37 weeks gestation, including women with previous CS(s) The Robsons 10 group classification of CD 38

39. Collecting delivery data for Robsons classification The WHO Robsons Implementation Manual has proposed several methods for data collection according to Robsons Classification; The manual method The partial computerized implementation Customized health information technology tools such as an electronic medical record for data collection 39

40. The Sri Lankan situation Sri Lanka is low middle income country with very little use of information technology in the field of health data collection Most data are collected in paper format and then transferred to electronic format for analysis and recommendations Thus Sri Lanka does not categorize CD according to Robsons classification Labour data according to Robsons classification in Sri Lanka has only been done in isolated research settings. 40

41. Introducing a smartphone app for the robsons classification W e developed a partial computerized system to collect data on Robsons classification RobsApp® The main considerations given when developing this app was E ase of data entry, Ease of un-interrupted data entry, Ease of integration into the routine work flow, Ease of administration, The scalability of the web based smartphone application for wider deployment potential 41

42. Collecting data in the RobsApp® The main purpose of the RobsApp® was for obstetric audits and specifically understanding the reasons for the rising Caesarean Section (CS) rates. 42

43. Following functionalities was planned from initial stages of App development. Collection of the required six variables (parity, past CS, number of fetuses, presentation, gestational age, onset of labour) Recording of the data in a database for later data analysis Using the WHO algorithm to classify the mothers into the individual Robson Group Automate the data analysis based on the Robson criteria and the Multi-Country Survey (MCS) * Use this data as audit standards for future use in the unit to propose service improvements *Souza JP, Betran AP, Dumont A, de Mucio B, Gibbs Pickens CM, Deneux-Tharaux C, et al. A global reference for caesarean section rates (C-Model): a multicountry cross-sectional study. BJOG [Internet]. 2016 Feb [cited 2021 May 30];123(3):427–36. Available from: http://www.ncbi.nlm.nih.gov/pubmed/26259689 43

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45. Validating the RobsApp® The next most important task was to validate the RobsApp® to be able to use in clinical setting A retrospective descriptive study was done at DSHW based on medical records. Study Population: Records of all deliveries of the month of August 2017 occurring at the Professorial Unit of De S oysa Maternity Hospital Sample size: Calculated for an expected Kappa value of 0.85, precision of 0.1, outcome percentage of 10% and α error of 5% was 300 Sampling Method: Records of deliveries were consecutively selected until sample size was achieved Data Collection: Deliveries were coded using the RobsApp® by a trained data entry officer Same deliveries were manually coded according to the Robson’s classification by a Consultant Obstetrician 45

46. Data Analysis: Percentage agreement and Kappa statistic (for inter-rater agreement) were calculated Coverage, Feasibility and Time efficiency of using the RobsApp ® were assessed qualitatively Results Robson’s category Percentage agreement Kappa statistic Significance 1 84.3% 0.83 P<0.001 2a 94.6% 0.82 p<0.001 3 93.7% 0.81 P<0.001 4a 95.3% 0.77 p<0.001 5a 97.6% 0.89 P<0001 5b 99.7% 0.96 P<0.001 6 99.7% 0.94 P<0.001 7 99.7% 0.92 P<0.001 8 99.7% 0.92 P<0.001 9 100.0% 1.0 P<0.001 10 99.3% 0.91 P<0.001 Percentage agreement and Kappa statistic of the Robson’s categories using the app and the consultant’s assessment 46

47. Using the RobsApp® RobsApp is hosted at Siteground servers which are highly customized and based on a Google Cloud infrastructure A master database file will be generated in the following 5 file formats - CSV for MS Excel, open document spreadsheet, CSV, pdf and XML formats This data can be migrated to SPSS, SAS or any other statistical package of choice for further data analysis for future audits. 47

48. 879 11880/19 19 Multipara No past CS Spontaneous Singleton More than 37 Cephalic Normal Live birth FTND no elective CS no emergency CS Missing Data On : DSHW/15 880 11480/19 35 Nullipara No past CS Spontaneous Singleton Less than 37 Cephalic CS Live birth FTND Multiple Fetuses and T2 breech no emergency CS Missing Data On : DSHW/15 881 11566/19 25 Multipara No past CS Spontaneous Singleton More than 37 Cephalic Normal Live birth FTND no elective CS no emergency CS Missing Data On : DSHW/15 882 11861/19 22 Multipara No past CS Spontaneous Singleton More than 37 Cephalic Normal Live birth FTND no elective CS no emergency CS Missing Data On : DSHW/15 883 11849/19 NA NA NA Singleton NA NA Normal Live birth None no elective CS no emergency CS Missing Data On : Presentation Labor Parity Past C DSHW/15 884 11356/19 26 Multipara No past CS NA Singleton More than 37 Cephalic CS Live birth FTND no elective CS no emergency CS Missing Data On : Labor DSHW/15 885 11831/19 24 Nullipara No past CS No labour or PreLabor CS Singleton More than 37 Cephalic Normal Live birth FTND no elective CS no emergency CS Missing Data On : DSHW/15 886 11690/19 29 Nullipara No past CS Spontaneous Singleton More than 37 Cephalic CS Live birth FTND no elective CS CTG abnormalities Missing Data On : DSHW/15 887 11661/19 23 Nullipara No past CS Spontaneous Singleton More than 37 Cephalic Normal Live birth FTND no elective CS no emergency CS Missing Data On : DSHW/15 888 11882/19 35 Multipara No past CS Spontaneous Singleton More than 37 Cephalic Normal Live birth FTND no elective CS no emergency CS Missing Data On : DSHW/15 889 10817/19 31 Multipara No past CS No labour or PreLabor CS Singleton Less than 37 Cephalic CS Live birth FTND no elective CS labor emergency Missing Data On : DSHW/15 890 10410/19 23 Nullipara No past CS No labour or PreLabor CS Singleton Less than 37 Cephalic CS Live birth FTND no elective CS CTG abnormalities Missing Data On : DSHW/3 891 10708/19 36 Multipara No past CS No labour or PreLabor CS Singleton Less than 37 Cephalic Normal Live birth FTND no elective CS CTG abnormalities Missing Data On : DSHW/3 892 11181/19 28 Nullipara No past CS No labour or PreLabor CS Singleton More than 37 Cephalic Normal Live birth FTND no elective CS no emergency CS Missing Data On : DSHW/3 An exel sheet of raw data generated by the RobsApp® 48

49. Collecting data in RobsApp® MBBS graduates was trained to use the RobsApp ® A 30-minute training included the access to the RobsApp® with a URL Following the training, data collection was carried out prospectively After an initial training only 2 min was needed to fill the relevant fields in the app which was opened in the smartphone of the data collector 49

50. Using RobsApp® in research setting A study was done using the newly developed Robsapp ® for evaluating the caesarean section rates according to robsons classification in DSWH Study period was 2019 April to October, all women giving birth during the study period were included in the study The data was collected prospectively and research assistants used their own smart phones for the data collection (BYOD principle) 50

51. Results of the study Table 1:- Major findings of the study Study sample (women) 1712 Overall CD rate during the study period (ward 3+15) 33% Instrumental delivery rate 03% Emergency CD rate 49.6% Robsons group with h ighest number of deliveries Group 1 (27.3%) Highest contribution to CD rate was Robson 5a (women with one previous section) 20.2% Highest contributor to Emergency CD was non reassuaring CTG (Fetal distress) 32.1% 51

52. Robson group Number of CS in group Number of women in group Group size a (%) Group caesarean section rate b (%) Absolute group contribution to overall CS rate c (%)   Relative contribution of group to overall CS rate d (%)   1 82 468 27.3 17.5 4.8 14.5 2a 59 184 10.7 32.1 3.4 10.4 2b 37 41 2.4 90.2 2.1 6.5 3 40 431 25.2 9.3 2.3 7.1 4a 24 138 8.1 17.4 1.4 4.2 4b 2 2 0.1 100 0.1 0.4 5a 114 155 9.1 73.5 6.7 20.2 5b 39 42 2.5 92.9 2.3 6.9 6 37 39 2.3 94.9 2.2 6.5 7 29 34 2.0 85.3 1.7 5.1 8 24 33 1.9 72.7 1.4 4.2 9 5 5 0.3 100 0.3 0.9 10 73 140 8.2 52.1 4.3 12.9 Total 565 1712 100 NA 33.0 100.0 Table 2 – Representation of the data set according to Robson guideline a Group size (%) = n of women in the group / total N women delivered in the hospital x 100 b Group CS rate (%) = n of CS in the group / total N of women in the group x 100 c Absolute contribution (%) = n of CS in the group / total N of women delivered in the hospital x 100 d Relative contribution (%) = n of CS in the group / total N of CS in the hospital x 100 52

53. Table 3 : Indications for Emergency CD Indications for emergency CS Frequency Percentage Failure to progress in spontaneous labour 40 14.2 Failure to progress in induced labour 44 15.7 2nd stage CS 13 4.6 CTG abnormalities 90 32.1 PET or medical complications 40 14.3 Meconium-stained liquor 24 8.6 Fetal growth restriction (severe) 6 2.1 Labour emergency 14 5.0 Failed trial of labour after caesarean section (TOLAC) 15 5.4 Total 280 100.0 53

54. T able 4. Robsons manual has suggested using several steps Current study has managed achieve the recommended data quality as suggested by the Robson manual Steps to assess quality Robson interpretation MCS population Our study Total numbers of CS and of women delivered in your hospital   NA Total CS = 565 Total deliveries = 1712 Matches with the total numbers Size of the group 9 It should be < 1% 0.4% 0.3% Caesarean section rate in group 9 Should be 100% 88.6% 100% MCS : multi country survey conducted by WHO which is used form a “reference population” for comparison 54

55. Table 5 Assessing the type of study population in comparison to Robson guideline and other studies. Step Robson guideline a MCS reference population b DSHW 2017 c Our findings Size of group 1 +2 This usually represents 35-42% of obstetric population of most hospitals. 38.1%   38.1% 40.5% Size of groups 3+4 This usually represents about 30% of women. 46.5%   37.3%   33.4% Size of group 5   7.2% 10.9% 11.5% Size of groups 6+7 3%–4%   2.7% 3.4% 4.3% Size of group 8 1.5%–2% 0.9% 1.1% 1.9% Size of group 10 <5% 4.2% 7.8% 8.2% Ratio of the size of group 1 versus group 2 Ratio 2 or higher   Ratio 3.3 Ratio 1.5 Ratio 2.1 Ratio of size of group 3 versus group 4 Ratio more than 2 Ratio 6.3   Ratio 2.6 Ratio 3.1 Ratio of size of group 6 versus group 7 Ratio usually 2 Ratio 0.8   Ratio 1.2 Ratio 1.1 Step Robson guideline MCS reference population Our findings Size of group 1 +2 This usually represents 35-42% of obstetric population of most hospitals. 38.1%   40.5% Size of groups 3+4 This usually represents about 30% of women. 46.5%   33.4% Size of group 5   7.2% 11.5% Size of groups 6+7 3%–4%   2.7% 4.3% Size of group 8 1.5%–2% 0.9% 1.9% Size of group 10 <5% 4.2% 8.2% Ratio of the size of group 1 versus group 2 Ratio 2 or higher   Ratio 3.3 Ratio 2.1 Ratio of size of group 3 versus group 4 Ratio more than 2 Ratio 6.3   Ratio 3.1 Ratio of size of group 6 versus group 7 Ratio usually 2 Ratio 0.8   Ratio 1.1 55

56. Table 6 Steps to assess CS rates according to Robson guidance. Findings are compared with MCS reference population. Step Robson guidance a MCS reference population b Our study CS rate for group 1 Rates under 10% are achievable 9.8% 17.5% CS rate for group 2 Consistently around 20-35% 39.9% 42.7% CS rate in group 3 Normally no higher than 3% 3% 9.3% CS rate in group 4 Rarely should be higher than 15% 23.7% 81.6 % CS rate in group 5 Rates of 50-60% are considered appropriate provided you have good maternal and perinatal outcome 74.4% 77.7% CS rate in group 8 Usually around 60% 57.7% 72.7% CS rate in group 10 In most populations usually around 30% 25.1% 52.1% contribution of Groups 1, 2 and 5 to the overall CS rate These three groups combined normally contribute to 2/3 (66%) of all CS performed in most hospitals. 63.7% 58.5% Contribution of Group 5 to the overall CS rate   28.9% 27.1% 56

57. Important findings of our study The caesarean section rate of 33% is far more than the recommended rate by the WHO which proposes a rate of 10-15 %. High population with at least one past CD (Group 5), measures needed to take to reduce this amount The CS rate in groups 6 and 7 were 94.9% and 85.3% respectively and overall 90.4 % of all breeches had a CD in our study The proportion of preterm deliveries in our unit was much higher than the Robson reference rage of < 5 % as well as the multiple pregnancies in our unit. 57

58. Findings cont.…… Significantly lower population of women in Group 3 and 4 (Multipara without scar) We had a very high rate of CD in nulliparous inductions (42.7%) High CD rate in group 3(9.3% compared with Robsons guidance of 3%) The rate of CS in group 5 (all multiparous women with a previous one or more CS) was 77.7 in our unit (Robsons 50-60%) A lmost half of the CD carried out at the unit are emergency CD. Fetal distress is the highest contributor followed by failure to progress in induced labour 58

59. Using the “ RobsApp ” Professorial unit DSHW and comparing it with past attempts of robsons classification in the same unit Prospective data collection enables us to analyze data in a continuous manner in over a period of time. This can easily achieved with the R obsApp ® N eeds minimal resources and thus it would be more sustainable than the orthodox data collection methods Financially less costly and so more feasible to continue 59

60. A similar study was done by Senanayake et al. (a) using paper based data collection in the same unit DSHW from July 2015 to June 2017 We studied the difference of each categories which had occurred over time by comparing data obtained from the RobsApp ® with S enanayake et al study Senanayake , Hemantha , et al. "Implementation of the WHO manual for Robson classification: an example from Sri Lanka using a local database for developing quality improvement recommendations."  BMJ open  9.2 (2019): e027317 60

61. Results of the study T he CD rate had significantly increased from 30.0% in 2017 to 33% in 2020 at the same unit (p<0.01 ). Overtime group 5 (at least on CD in the past) has increased from 10.9% in 2017 to 11.5% in 2020 . Increase trend in Preterm deliveries (1.1% to 1.9%) Size of Gp 3+4 (multiparous women without scar) is significantly lower that 2017 study and MCS study (33.4% Vs 37.3 and 46.7) There is a reduction of contribution to CD by group 5 to the total CD from 29.6% to 27.1% over time (P <0.05 ) Group 6 and7 (all women with a single breech presentation) contribution to total CSs had increased to 11.6% from 9.1% from 2017 to 2020 61

62. Using the RobsApp® in the multicenter setup Heterogeneity of data is a major obstacle in comparing CS rates in different setups in the country Thus when attempting to reduce CS rates, same guideline may not be valid for each and every unit in the country RobsApp ® as the solution The main advantage of Robsons classification is the scalability of the data collection in to national level RobsApp being a web based app and uses the BYOD computer usability principle both human resource and cost for continued data collection would be minimum at national level. 62

63. Using the robsApp ® as to compare CD rates in 3 professorial units in the country; a multi center study A multicenter study is planned to be carried by the same investigators to assess the scalability of the App to national level. Professorial units of three major hospitals were recruited for the above study namely De Soysa hospital for Women, teaching Hospital Karapitiya and Teaching Hospital Anuradhapura were recruited to the study. All the women admitted during a calendar month were included in the pilot study and data were analyzed centrally 63

64. Lessions learned from the pilot study Missing data: Multi center coordination would be more difficult than a single center data collection and there is higher risk of missing data We plan to introduce a proforma for the 6 variables need to be filled in Robsons classification The other solution would be the house officer himself /herself to fill the data using his/her smartphone Differentiating the different units where the data were uploaded The additional field that is included to locate the institute need to be filled as a mandatory procedure, otherwise the data analysis will be flawed 64

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66. Finally journey continues…………… Where do we go from here? We have no doubt that this RobsApp can be used nationally to generate data which are accurate, reliable, reproducible to be used national level research and audit The app has generated international interest to be used in collaboration with other low and low middle income countries as a potential less resource intensive audit tool. 66

67. Aknowladgements My parents The president and the Council of SLCOG The wife and family memebers of late Dr Nalin Rodrigo My father in law and mother in law and family My teaches and supervising consultants My mentor Prof Hemantha Senanayake My department collogues My Sister and my two brothers 67

68. Finally : my family 68