Implementing Global Standards
of Maternal and Neonatal Healthcare at Healthcare Provider Level: A Strategy for Disseminating
and Using Guidelines
Robert H. Johnson, MD, MPH
  
To address the problems of maternal and neonatal health in developing countries, a standard of care is required to define level of performance, improve quality of services provided and, ultimately, reduce maternal and newborn deaths. The standard of care should be based on state-of-the-art scientific information and focus on the woman and her baby in the context of her family and community. A country's standards are embodied in its policy and service delivery guidelines.
The policy guidelines document is the more general one that provides the basic outline for the provision of services, while the service delivery guidelines contain the detailed, technical information that healthcare providers need to implement the national policy guidelines as they provide patient care. Countries can use international resource materials, such as those developed by WHO and JHPIEGO, as the basis for their national policy documents, and can also adapt them to create country-specific service delivery guidelines that are clinically sound and up-to-date.
Development and implementation of national guidelines is a complex process involving many levels of the healthcare system. Essential activities that have to occur at the national, regional and/or district levels in order to implement guidelines at the healthcare provider level usually include a number of steps:
- identifying stakeholders and gaining consensus on the need for change;
- forming a national advisory group;
- developing and revising draft national policy guidelines;
- developing and revising draft national service delivery guidelines;
- validating draft documents through review by key stakeholders external to
the advisory group;
- endorsing officially the policy document and service delivery guidelines;
- disseminating policies and guidelines at the national level;
- disseminating policies and guidelines to the regional and district levels;
- ensuring that systems are in place to support quality provision of care;
- motivating providers and ensuring that they have skills; and
- ensuring involvement of the community.
For national policies and guidelines to have impact at the level of healthcare provision, effective systems for human resources, training, supervision, supplies, logistics, drugs and equipment, referral, and monitoring and evaluation must be in place. These systems both support and are supported by implementation of the guidelines, and help to ensure provision of the high quality of care embodied in the national standards. Ultimately, community members must perceive these standards as their right, and then mobilize to bring about their full and effective implementation because, in the final analysis, the standards are implemented for the benefit of women, their newborns and their communities.
This strategy paper builds on the DAU process defined and described by WHO for implementation of technical guidance materials by international agencies and programs. It offers numerous practical recommendations for implementation of guidelines at the country and healthcare provider level.
As described in this paper, the process of implementing service delivery guidelines at the level of healthcare providers starts with the development or refinement of guidelines in a particular country. International resource materials developed by international technical assistance organizations such as WHO, UNICEF and USAID's agencies and contractors (e.g., BASICS, JHPIEGO, Save the Children) serve as sources of information on best practices and evidence basis, and may even provide a prototype upon which national guidelines can be based. These international materials support the development of national guidelines, but for the purpose of this paper, the development and distribution of international resource materials themselves are not considered part of the process of developing and implementing national guidelines.
It is a common error to think of guidelines implementation as a linear process starting with the development of global prototypical documents and ending with their ultimate implementation by a country's healthcare providers. In fact, international resource materials serve only as models or inspiration for decision-makers and planners in a country seeking to reduce maternal and neonatal deaths. National authorities, working with their collaborators, take from those materials up-to-date information on best practices, standards of care and the evidence for those standards and practices, and then build unique national policy documents and service delivery guidelines. Even if the final national documents strongly resemble the international resource materials, they are still two entirely different entities. The national team finishes with the international resources and puts them aside. The active, living documents are the country's own, and it is these that are nationally implemented. This strategy paper describes the process of guidelines implementation from this point of view.
Reduction of maternal and neonatal mortality continues to be one of the greatest challenges to human development. During the last decade, projects to reduce maternal and neonatal mortality have focused on various interventions, including the risk approach, training of traditional birth attendants and improved maternal nutrition—without achieving the anticipated improvements.
Although the problem of reducing maternal and neonatal mortality is complex, the 1997 Safe Motherhood Technical Consultation in Sri Lanka concluded that the single most critical intervention in safe motherhood is the presence of a skilled birth attendant1 at labor and childbirth, with transport to emergency obstetric care available in case of emergency.2
How can we ensure that providers are competent to provide maternal and neonatal healthcare? In the health field, as in many other professions, the foundation of high quality services is the use of standards. Standards of care inform healthcare providers about what is expected of them and what they should do to deliver high quality services at each level of the healthcare system. They specify the continuum of care that is necessary to improve maternal and neonatal outcomes. Standards promote quality care, delivered in the most appropriate way, by the most appropriate personnel. The likelihood of ensuring high quality care is increased when skilled attendants perform their jobs competently and their competence is verified by comparing their performance to evidence-based standards of care. Furthermore, standards can empower women and
communities, giving them a tool to advocate for improved healthcare.
This document examines the critical pathways to implementing national service delivery guidelines at the healthcare provider level. These guidelines will have been developed in harmony with national policies, which in turn, have been revised in accordance with global standards using international, evidence-based resource material. This paper provides guidance to ministries of health and the agencies that support them in their efforts to improve the quality of care in their countries.
1Skilled birth attendants are defined as "People with midwifery skills (e.g., doctors, midwives and nurses) who have been trained to proficiency in the skills to manage normal deliveries, [as well as] diagnose and manage or refer complicated cases." MotherCare Policy Brief 3, May 2000.
2MotherCare. 2000. Policy Brief 3. Improving Provider Performance: The Skilled Birth Attendant. Summary of a MotherCare Meeting, 2–4 May 2000.
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