The words "standard" and "guideline" are each defined in many different ways and sometimes are even used interchangeably. This paper seeks to use the most generally accepted definitions of the terms.
Standards
WHO defines a standard as an agreed-upon level of performance that specifies what action should be taken. It serves as a benchmark upon which to make judgments. It must be achievable, observable, desirable and measurable. Standards of care for maternal and neonatal health should be evidence-based (supported by current scientific knowledge) and focus on the woman and her baby in the context of her family and community.
Standards of care are the basis for:
- education and training curricula (pre- and inservice);
- content for training manuals, clinical care protocols and guidelines;
- identification of gaps in technical or organizational performance for quality programs;
- supervisory and management systems;
- essential equipment, supplies and drug lists;
- job descriptions and deployment of personnel;
- essential level of care and referral criteria; and
- measurable outcomes.
Standards allow provider training and performance to be consistent at all levels of the healthcare system and provide the means to ensure uniformity of the healthcare delivery practices needed to support quality clinical services. However, standards can be implemented consistently in a country only if there is an effective and efficient healthcare delivery system in place. Components of the system should link into a continuum of care that has well-defined responsibilities at each level and the necessary infrastructure to support these services. Standards help to identify deficiencies in the system.
Guidelines
The word "guidelines" is a generic term for various documents that describe how standards are achieved. Two broad types of guidelines exist at the national level: policy guidelines and service delivery guidelines. Policy guidelines for maternal and neonatal healthcare are the government's official statement about standards for maternal and neonatal health services; they can be considered a management tool for achieving standards. In addition to being evidence-based, they reflect individual client demands, the community's perceived needs and the overall healthcare situation in the country. Policy guidelines describe:
- which services are to be officially offered;
- who may receive these services (e.g., any income restrictions);
- who will deliver the services (i.e., categories of healthcare providers);
- where these services will be delivered (i.e., at what level of the healthcare system);
- how often certain services are to be delivered (e.g., how many antenatal care visits); and
- what the minimal acceptable level of performance is for each service offered.
Policy guidelines do not contain the technical information needed to provide services; rather, they serve as a general outline for the provision of services.
Service delivery guidelines are a technical tool for achieving standards, and they provide the detailed information needed to implement the national policy guidelines. They are used by healthcare workers throughout the system as the source of specific, up-to-date information about the maternal and neonatal health services offered in a country, as well as general information needed by healthcare workers to provide high quality maternal and neonatal health services. Service delivery guidelines complement policy guidelines by:
- describing the components of maternal and neonatal health services, including protocols on how to perform those services;
- introducing related components needed for quality service provision, such as the principles and procedures for infection prevention practices;
- explaining how healthcare providers should relate with mothers-to-be, new mothers and their babies;
- recommending how maternal and neonatal services should be organized at the various levels of the country's healthcare system; and
- serving as the basis for maternal and neonatal health learning and resource materials, the maternal and neonatal component of curricula for preservice education and evaluation systems for training and healthcare delivery.
In some countries, service delivery guidelines comprise several different documents, such as a service standards document, a document on service protocols and procedures, and a service plan. For the purpose of this paper, all these documents will be considered in the category of service delivery guidelines.
International Resource Materials
Well-developed international resource materials bring together global lessons learned, international evidence and diverse perspectives, and serve as a "one-stop-shop" for collective global experience from which individual countries can benefit. Use of these materials by national ministries of health helps ensure that countries have state-of-the-art information upon which to base their standards and guidelines. Materials containing international standards based on evidence and best practices contribute substantially to national policy documents. More specifically, materials that have been formulated as prototypic manuals or guidelines can be adapted easily to become national service delivery guidelines. WHO and JHPIEGO, working both independently and in collaboration with each other, have developed a considerable body of evidence-based material that sets global standards and defines appropriate protocols and procedures for maternal and neonatal healthcare for even the lowest-resource settings. These materials can be readily adapted to most country situations.
Table 1 describes the four WHO and JHPIEGO technical manuals that form an essential maternal and neonatal healthcare package.
These manuals provide the evidence-based technical guidance for justifying best practices and, together, can be used as the basis for clinical care standards in countries around the world. Their content can be adapted within the framework of the needs, resources and priorities of specific countries to contribute to the development of national policies and service delivery guidelines.
Table 1. Components of the Essential Maternal and Neonatal Healthcare Package
|
MANUAL |
INTENDED AUDIENCE |
FOCUS |
|
Essential Care Practice Guidelines
(WHO) |
Healthcare personnel at all levels who provide
maternal and neonatal healthcare |
Basic care during normal pregnancy, labor and
childbirth; early identification of complications and pre-referral
treatment |
|
Basic Maternal and Newborn Care
(JHPIEGO with substantial contributions by BASICS, American
College of Nurse-Midwives) |
Midwives, nurses and other healthcare
professionals who provide maternal and neonatal healthcare |
Refocused antenatal care; early detection of
complications; normal labor and childbirth; and normal postpartum
care, including care of the newborn
|
|
Managing Complications in Pregnancy and
Childbirth (WHO and JHPIEGO) |
Doctors and midwives at institutions offering
comprehensive essential obstetric care (CEOC) |
Diagnosis and treatment of complications of
pregnancy, childbirth and the immediate postpartum period,
including immediate problems of the newborn |
|
Care of the Sick or Low Birth Weight Newborn
(WHO and JHPIEGO with BASICS) |
Doctors, midwives and nurses at institutions
offering CEOC |
Diagnosis and treatment of principal newborn
problems, including low birth weight |
By working with and adapting global documents such as those described above, national ministries of health can efficiently and rapidly produce materials and resources specific to their needs while ensuring that their national materials are up-to-date and clinically sound.
