Abstract
BackgroundObstetric guidelines are useful to improve the quality of care. Availability of international guidelines has rapidly increased, however the contextualization to enhance feasibility of implementation in health facilities in low and middle-income settings has only been described in literature in a few instances. This study describes the approach and lessons learned from the ‘bottom-up’ development process of context-tailored national obstetric guidelines in middle-income country Suriname.MethodsLocal obstetric health care providers initiated the guideline development process in Suriname in August 2016 for two common obstetric conditions: hypertensive disorders of pregnancy (HDP) and post partum haemorrhage (PPH).ResultsThe process consisted of six steps: (1) determination of how and why women died, (2) interviews and observations of local clinical practice, (3) review of international guidelines, (4) development of a primary set of guidelines, (5) initiation of a national discussion on the guidelines content and (6) establishment of the final guidelines based on consensus. Maternal enquiry of HDP- and PPH-related maternal deaths revealed substandard care in 90 and 95% of cases, respectively. An assessment of the management through interviews and labour observations identified gaps in quality of the provided care and large discrepancies in the management of HDP and PPH between the hospitals. International recommendations were considered unfeasible and were inconsistent when compared to each other. Local health care providers and stakeholders convened to create national context-tailored guidelines based on adapted international recommendations. The guidelines were developed within four months and locally implemented.ConclusionDevelopment of national context-tailored guidelines is achievable in a middle-income country when using a ‘bottom-up’ approach that involves all obstetric health care providers and stakeholders in the earliest phase. We hope the descriptive process of guideline development is helpful for other countries in need of nationwide guidelines.
Highlights
Obstetric guidelines are useful to improve the quality of care
Guidelines are known to improve the quality of care, but international guidelines are often not directly applicable for low- and middle-income countries (LMIC) due to the lack of personnel or resources
Determine how and why women died The substandard care analysis of the extracted maternal deaths related to hypertensive disorders of pregnancy (HDP) (n = 19) and post partum haemorrhage (PPH) (n = 21) in Suriname reveals that most substandard care factors are third delay factors due t a lack of quality of care [11]
Summary
Obstetric guidelines are useful to improve the quality of care. Availability of international guidelines has rapidly increased, the contextualization to enhance feasibility of implementation in health facilities in low and middle-income settings has only been described in literature in a few instances. This study describes the approach and lessons learned from the ‘bottom-up’ development process of context-tailored national obstetric guidelines in middle-income country Suriname. In low- and middle-income countries (LMIC), where informal sharing of knowledge and experience-based decision-making often dominates, the development and implementation of feasible clinical guidelines are key to improve quality of evidence-based, respectful maternity care [2]. Evidence about guideline implementation strategies in low- and middle-income countries has increased in the past years and a number of enablers of effective impementation have been identified [3, 4]. By creating appropriate guidelines tailored to the context, use in local reality is ensured and sustainable adherence is created [7,8,9]
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