We have previously noted on HIFA the gaps between WHO international clinical guidance and national guidelines, and between national guidelines, facility-level guidelines and actual practice. Surprisingly, 'examples of adaptation and implementation of clinical guidelines in low-resource settings are scarce, both within and beyond maternal health'.
In this fascinating study 'a pocket guide on locally achievable maternity care was co-created with birth attendants... The aim was to create locally achievable and easy-to-use guidelines to assist birth attendants in providing best possible intrapartum care with the constrained resources available. We adapted existing international guidelines,5–7 and we conducted systematic literature searches when we had to deviate from the recommendations to reach reality. Our modifications included reducing the frequency of clinical assessments, reducing the information load and avoiding ambiguity within recommendations'.
The authors noted: 'When starting the study in October 2014, different clinical guidelines on intrapartum care, including the World Health Organization’s (WHO’s) Guidelines for managing complications in pregnancy and childbirth, were available in the hospital, but rarely used.'
Citation, abstract and a comment from me below. Full text here: https://www.who.int/bulletin/volumes/97/5/18-220830/en/
CITATION: WHO Bulletin: Local adaption of intrapartum clinical guidelines, United Republic of Tanzania
Nanna Maaløe, Tarek Meguid, Natasha Housseine, Britt Pinkowski Tersbøl, Karoline Kragelund Nielsen, Ib Christian Bygbjerg & Jos van Roosmalen
Bulletin of the World Health Organization 2019;97:365-370. doi: http://dx.doi.org/10.2471/BLT.18.220830
Problem: Gaps exist between internationally derived clinical guidelines on care at the time of birth and realistic best practices in busy, low-resourced maternity units.
Approach: In 2014–2018, we carried out the PartoMa study at Zanzibar’s tertiary hospital, United Republic of Tanzania. Working with local birth attendants and external experts, we created easy-to-use and locally achievable clinical guidelines and associated in-house training to assist birth attendants in intrapartum care.
Local setting: Around 11 500 women gave birth annually in the hospital. Of the 35–40 birth attendants employed, each cared simultaneously for 3–6 women in labour. At baseline (1 October 2014 to 31 January 2015), there were 59 stillbirths per 1000 total births and 52 newborns with an Apgar score of 1–5 per 1000 live births. Externally derived clinical guidelines were available, but rarely used.
Relevant changes: Staff attendance at the repeated trainings was good, despite seminars being outside working hours and without additional remuneration. Many birth attendants appreciated the intervention and were motivated to improve care. Improvements were found in knowledge, partograph skills and quality of care. After 12 intervention months, stillbirths had decreased 34% to 39 per 1000 total births, while newborns with an Apgar score of 1–5 halved to 28 per 1000 live births.
Lessons learnt: After 4 years, birth attendants still express high demand for the intervention. The development of international, regional and national clinical guidelines targeted at low-resource maternity units needs to be better attuned to input from end-users and the local conditions, and thereby easier to use effectively.
COMMENT (NPW): We need more examples of approaches to develop national guidelines and/or guidelines for individual facility level. To increase impact and reduce duplication of effort, the ideal would be: for WHO to make international guidance available (or at least easily adaptable) for low-resource settings, for more support at national level to adapt guidelines, and for better coordination among hospitals to share experience and resources. What appears to be missing from the above account is any reference to national guidelines. Logically it would make sense for facility-level guidelines to be based on national guidelines rather than WHO international guidance? If such national guidelines do not exist (or are out of date or poor quality) then the key question would be: how to develop/improve them? It would be interesting to see whether the Zanzibar guidance is replicated/adapted across Tanzania - while the current study was exemplary in involving birth attendants in the development of the guidelines, it appears to be sidestepping the larger question of national guideline development.
Best wishes, Neil
Coordinator, mHIFA Project (Mobile Healthcare Information For All)
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