The current state of global maternal health guidelines
Guidelines form a cornerstone of quality maternal health care. Here Katie Millar, from the University of California San Francisco and co-author on The Lancet paper by Suellen Miller et al, provides an overview of the role and current status of guidelines to improve maternal health. We will also explore the role of evidence to develop guidelines, how they should be used and measurement.
What is the role of guidelines in maternal health care?
To realise the greatest impact on maternal health outcomes, women need universal access to quality of care based on evidence-based interventions. Providers need to know what these are and the skills and commodities to provide them, so that effective, respectful care can be delivered to women and newborns. Currently, an absence of guidelines and a chasm between guidelines and how care is delivered yields care that is “too little, too late” (insufficient care) and “too much, too soon” (over-medicalized care). Each of these extremes results in poor maternal health outcomes.1 We look at “too little, too late” and “too much, too soon” care in more detail later this week.
Well-developed guidelines summarise evidence-based interventions using the best available research to guide women’s and providers’ decisions, and improve maternal health outcomes.1 Guidelines based on high-quality evidence, together with effective implementation strategies,2-4 have the potential to assist providers to make the right decisions at the right time, and avoid the harmful extremes of “too little, too late” and “too much, too soon”.1 Conflicting recommendations can confuse guideline users,5 and create uncertainty as to why differences exist, and may even result in some women getting care that is not evidence-based and of poor quality.
What is the current status of maternal health care guidelines?
The quality of maternal health guidelines depends on both the robustness of available evidence and the ability of maternal health leaders to compile, critically analyse, and synthesize evidence. These critical processes of analysing and synthesizing to create high-quality guidelines are often performed at the global level by the World Health Organization (WHO) or other reputable and experienced groups, such as the UK-based National Institute for Health and Care Excellence (NICE) or the International Federation of Gynaecologists and Obstetricians (FIGO)6.
However, individual countries and health systems often produce their own reviews and guidelines. In our review of guidelines, we found many recommended interventions in agreement with evidence produced by WHO and others, but for a few interventions, conflicting recommendations were published. These may be appropriate, and due to differences in countries’ epidemiological profiles, resources or context. Alternatively, inconsistencies may be inappropriate, and due to insufficient evidence or an incorrect interpretation of the evidence. Without further analysis, we cannot provide definitive explanation. For example, in rural poor contexts where gestational diabetes is still very rare and treatment options may not be available, a screening test for gestational diabetes may not be appropriate. However, such adaptations to guidelines would need to be based on regular monitoring of epidemiological profiles and consultation with country expert teams. We noted in our review of guidelines that no single guideline of sufficient quality was published from low-income countries, indicating that too little is invested to adapt guidelines to local contexts.1
Recommendations for routine interventions that are not evidence-based result in care that is both “too little, too late” and “too much, too soon”. While some inconsistencies may reflect contextual adaptation, there also exists a lack of international consensus around the evidence of benefits and harms of routine interventions.1 Inconsistencies in just one recommendation can cast doubt on the entire set of guidelines or even on the use of guidelines completely. Use of different systems for grading of evidence and different terminology can also create confusion for users and policy makers where there is insufficient evidence. In order to mitigate poor outcomes due to inconsistent guidelines, we analysed guidelines from the global to country level, the result of which is a set of recommended routine interventions for the antepartum, intrapartum, and postpartum period.1 Motherhood cannot be safe without consistent guidelines with clear, comprehensible steps to implementation.1
Inconsistent Guidelines: Hypothesized Causes1
|Appropriate causes of inconsistencies||Inappropriate causes of inconsistencies|
|Different prevalence of risk factor or disease (e.g. no malaria)||No evidence|
|Intervention not cost-effective||Not including all evidence|
|Poor synthesis of evidence|
|Different grading criteria|
Guidelines alone are not enough
While producing and disseminating high-quality guidelines is necessary, implementation strategies to support consistent implementation of evidence-based interventions are essential for improving maternal health outcomes. Currently, the lack of guideline adherence is a global health problem and much research has documented this failure as the “know-do gap”.7-9 Implementation strategies to improve the utilization of evidence-based guidelines may include training providers by using techniques such as in-service training, simulations, drills, supportive supervision, checklists, quality improvement approaches and financial incentives.3,4,10 In addition, the entire system, including women and communities, must be engaged and aware of guidelines so they can hold providers and health systems accountable for providing evidence-based care.11 Improvements in development and dissemination of clearly written guidelines, and better strategies for subsequent adherence, can help providers move beyond “too little, too late” and “too much, too soon”.1
How can quality of care and adherence to guidelines be measured?
Many difficulties exist in assessing both quality of care and adherence to guidelines. Since the mere access to facility and / or a skilled birth attendant are not always associated with quality of care and good maternal health outcomes, the WHO is currently consulting with global experts to provide a new framework on quality measurement techniques. It is vital to track adherence to guidelines in practice.
Current coverage data for the use of specific recommendations is scarce and makes assessment of “too little, too late” and “too much, too soon” rates difficult. This is especially true for routine maternity care.12 We urgently need research linked to quality improvement measures to assess current practices and respond with refined guidelines and implementation efforts at all levels of care and policy.1
As we saw in Week 1 of the course, differences in national- and regional-level epidemiological profiles and a shift in aetiology of obstetric complications from direct to indirect causes, require routine monitoring indicators and measurement systems for maternity care to be flexible and reactive to these changes. The need for a substantive research agenda regarding the causes, determinants, and interventions to address inadequate adherence to guidelines in different settings is evident.1
Evidence-based guidelines, implementation and accompanying data systems to measure intervention and outcome rates are critical to The Lancet Maternal Health Series’ Action Plan at both the national and global levels. Priority 5 of the Action Plan provides guidance moving forward, focusing on evidence, advocacy and accountability through improved metrics, implementation research, and resulting evidence-based maternal health care.13 Better guidelines and better measurement of all aspects of care, including routine care, are essential components. We will look at the Action Plan in more detail next week.
© The London School of Hygiene & Tropical Medicine