Bottom-up development of national obstetric guidelines in middle-income country Suriname

One of the most important steps to reduce maternal deaths in low and middle-income countries (LMIC) is improving the quality of care provided to pregnant women. Guidelines are known to improve the quality of care, but international guidelines are often not directly applicable for LMIC due to the lack of personnel or resources. This in part reflects where and by whom the guidelines are often developed: international organizations, international colleagues or non-clinicians, who insufficiently consider the context in which these guidelines need to work.

In Suriname, a South American middle-income country, local health care providers initiated a guideline development strategy themselves (“bottom-up”). Local health care providers developed two obstetric guidelines about severe bleeding after childbirth (postpartum haemorrhage) and high blood pressure (hypertensive disorders) during pregnancy. This process consisted of a number of steps: first, it was studied how and why women died during pregnancy, childbirth or shortly after. Next, interviews with local health care providers were conducted, local clinical practice was observed, international guidelines were reviewed and the preliminary guidelines were developed. These guidelines were discussed nationally and consensus was reached for the final guidelines after which implementation began. This “bottom-up” approach, with early involvement of local health care providers proved essential to develop guidelines that are acceptable to everyone and guarantee implementation. These lessons can inform and support the guideline development processes in other countries.

Reducing maternal mortality remains a universal priority for clinicians, researchers and policymakers. The obstetric transition model describes five stages in which countries move, from high to low maternal mortality [1]. Phase three is considered a tipping point, in which predominantly direct causes of mortality persist, but as most women reach hospitals, improving the quality of care (skilled birth attendance, appropriate management of complications) becomes essential to further reduce mortality [1]. 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]. The most important known enabler is to use a multi-facetted strategy (i.e. combining different methods of implementation) instead of a single intervention (e.g. providing health care workers with existing guidelines) [3‐7]. Positive health care providers’ attitude towards the guidelines is strongly associated with adherence to the guidelines. The process of guideline development before implementation is critical. By creating appropriate guidelines tailored to the context, use in local reality is ensured and sustainable adherence is created [7‐9].

Suriname is an example of a country in obstetric transition phase three with a fairly high maternal mortality ratio (MMR) of 130 per 100.000 live births compared to other countries in Central and South America [10‐12]. Similar to most LMICs, the primary causes of maternal deaths in Suriname are postpartum hemorrhage (PPH) and hypertensive disorders of pregnancy (HDP) [11]. The majority of these deaths are due to ‘third delay’ factors linked to the quality of care, such as in-hospital delay of diagnosis and treatment [11, 13]. The introduction of nationwide guidelines for the clinical management of these complications is therefore a promising strategy to improve health outcomes.

Suriname is a middle-income country on the northeastern coast of South-America with 550.000 inhabitants in 2016 and almost 10.000 deliveries annually. Of all deliveries, 92% of women give childbirth in the five hospitals in the country, while 8% deliver in primary health care centers and 2% at home. Four hospitals are located in capital city Paramaribo and one smaller hospital is located on the far West-coast, Nickerie [14, 15]. In 2016, fifteen obstetricians, eight residents and approximately fifty midwives provided maternal care in the hospitals in Suriname. Obstetric care provision in Suriname is mainly influenced by Dutch guidelines (Nederlandse Vereniging van Obstetrie en Gynaecologie, NVOG) as residents follow 2 years of their training in the Netherlands [16, 17]. In addition, the American College of Obstetrics and Gynecology (ACOG) and the World Health Organization (WHO) guidelines are used [18‐21].

In 2015 and 2016 a national maternal death review committee was established, consisting of local obstetric health care providers. This committee audits all pregnancy-related deaths in the country. Among the recommendations are the implementation of national guidelines on the most important causes of maternal mortality and training emergency (obstetric) skills. Subsequently, the maternal death committee members initiated the bottom-up guideline development consisting of six-steps, as described below.

The six phases of the guideline development process were executed in a period of four months (Fig. 1).

We have presented the participatory approach of the development process of context-tailored national obstetric guidelines on HDP and PPH in Suriname. The process consisted of six steps: (1) determination of how and why women died, (2) interviews and observations of local clincal practice, (3) review of international guidelines, (4) development of a primary set of guidelines, (5) initiation of a national discussion about the guideline content and (6) consensus-based finalization of both guidelines.

The most important enabler of succesful guideline development was the bottom-up approach with early involvement of local, intrinsically motivated, health care providers. Important barriers were the inconsistencies between international recommendations, the unavailability of easily adaptable guidelines and the use of several different international guidelines by health care providers which differed among each other.

In the assessment of causes of maternal deaths due to HDP and PPH in Suriname, we found that insufficient quality of care played the most important role. This led to the development of the guidelines. Our approach is aligned with the recommendations from the obstetric transition model, in which evidence-based guideline implementation is a key intervention to further reduce maternal mortality in countries in the third stage of transition [1, 37, 38]. Contrary to the more common maternal health guideline development approach (with a top-down mentality, in which experts distribute knowledge or guidelines without involvement of target users), our guideline development approach demonstrates how to succesfully bridge the gap between evidence-based international recommendations and local realities by involving end users from the earliest phases of guideline development to enhance final guideline use [3, 4, 8, 38]. This is crucial, as merely the existence of (international) guidelines does not guarantee implementation. Our assessment of practice in the hospitals in Suriname showed that guidelines for HDP and PPH were not routinely used and quality of decision-making was based on experience rather than evidence, as often reported from similar settings [5, 7, 8, 39]. Local health professions often considered the international guidelines unfeasible and impractical. Next to this, similar to other studies, we found that well-established international guidelines on HDP and PPH differ significantly in their recommendations and interpretation of underlying evidence that resulted in these recommendations [40‐42]. This suggests that a critical evaluation is necessary of how available evidence is used to develop global obstetric guidelines.

There were substantial differences in the management of HDP and PPH between hospitals. This is in part a reflection of the various clinical practices that influence care in Suriname with influences from Europe, the United States and the WHO. Yet, even in high-income countries with national guidelines endorsed by professional organizations, inter-hospital differences in management of HDP and PPH are reported [43, 44]. These findings underline the importance of involving also the end users in the guideline development process (i.e. health care providers and stakeholders involved in pregnancy, delivery and postpartum care).

Important barriers of guideline development that need to be elaborated upon is that some recommendations are not immediately accepted. In Suriname, for example, the use of magnesium sulfate for prevention of eclampsia was initially not accepted by all as healthcare workers were not yet familiar with this. Another barrier for Suriname is the fact that there is currently no regulatory framework for health professionals. We believe such framework would be relevant to reduce maternal deaths, especially by helping health care workers to monitor their delivered quality of care. A general barrier for the development of context-tailored obstetric guidelines is the fact that it is time consuming and resource demanding. We noticed that early involvement of end users, understanding their barriers and engaging all health care professionals are essential to ensure a fast guideline development process.

If more global consensus on the most important obstetric complications would be attained, with recommendations tailored at region or health care system resources and include easily-adaptable flowcharts or checklists, the local guideline development would be much more feasible. The WHO Handbook for Guideline Development is an example of a comprehensive tool for evidence-based guideline development, but also a very large document and it uses a time-consuming process that seems not readily achievable for most LMIC [45]. The recently published PartoMa study from in a low-resource referral hospital in Zanzibar, Tanzania, is one of the few examples of a systematic approach to evidence-based international recommendations adaptation to local reality and evaluation of it’s impact on health outcomes. Their ‘bottom up’ approach was similar to ours and appeared to be associated with significant reductions in stillbirths and improvement of treatment of hypertensive disorders of pregnancy [6, 7, 46]. The PartoMa Guideline Development in Zanzibar and our strategy in Suriname were both achievable due to the smaller size of the island or country [6, 7, 46]. However, when healthcare workers are fully engaged in the quality cycle of plan-do-check-act, nationwide improvement can also be made in larger countries [47].

Bottom-up development of context-tailored guidelines are achievable within a reasonably short timeframe. Important barriers for the guideline development process are the discrepancies between international recommendations, which require local consensus to be reached on key issues, and the unavailability of easily adaptable guidelines. The main enabler for both development and implementation is the involvement of local birth attendents from the early phases onwards to ensure use in local reality, drive change and create sustainable adherence. We recommend bottom-up context-tailored guideline development with early involvement of the end users.