Abstract
The process of adapting universal guidelines to local institutional and cultural settings is recognized as important to their implementation and uptake. However, clarity on what, why and how to adapt in an evidence-based manner is still somewhat elusive. Health providers in low and middle income country contexts often have to deal with widely present co-morbidities and social inequalities among pregnant women. Since neither of these problems finds adequate discussion within the usual guidelines, and given the continual pressures posed by resource scarcity, health providers respond through ad hoc adaptations inimical to maternal safety and equity. We argue for, and describe, a grounded process of systematic adaptation of available guidelines through the example of a handbook on maternal risks for primary care doctors and staff nurses. The systematic adaptation in this practical, action-oriented handbook builds on research for a long-standing community-based project on maternal safety and rights. It takes a case-based problem-solving approach. Reiterating guidelines and best practices in diagnostic decision-making and risk management, it indicates how these can respond to co-morbidities and social inequality via complex clinical cases and new social science information.
Key words: Maternal health, best practices, guidelines, co-morbidity, social inequality, capacity building
Mots Clés: santé maternelle, pratiques exemplaires, directives, comorbidité; inégalité sociale; r, enforcement des capacités
Résumé
Il est reconnu que le processus d’adaptation des directives universelles aux milieux institutionnels et culturels locaux importe pour l’application et l’adoption de ces directives. Quoi adapter, pourquoi le faire et comment s’y prendre en se fondant sur les preuves sont toutefois des questions auxquelles il n’existe pas de réponses claires. Les personnels de santé des pays à faible revenu et à revenu intermédiaire doivent souvent composer avec des comorbidités et des inégalités sociales largement répandues chez les femmes enceintes. Comme ces deux problèmes sont insuffisamment abordés dans les directives habituelles, et devant les pressions continuelles exercées par la rareté des ressources, les personnels de santé répondent par des adaptations ponctuelles parfois contraires à la sécurité des mères et à l’équité. Nous promulguons et décrivons un processus bien rodé d’adaptation systématique des directives disponibles en citant l’exemple d’un guide sur les risques maternels rédigé à l’intention des médecins de premier recours et des infirmières de soins généraux. Les adaptations systématiques présentées dans ce guide pratique et pragmatique tirent parti de la recherche effectuée pour un ancien projet communautaire sur la sécurité et les droits des mères. Le guide emploie une méthode de résolution de problèmes au cas par cas. En répétant les directives et les pratiques exemplaires en matière de décisions diagnostiques et de gestion des risques, le guide indique comment elles peuvent répondre aux comorbidités et aux inégalités sociales en les illustrant par des cas cliniques complexes et de nouvelles données de sciences sociales.
Footnotes
Acknowledgements: The handbook and the research informing it drew upon financial support provided by the International Development Research Centre, and institutional support provided by the Centre for Public Policy, Indian Institute of Management Bangalore. We are deeply grateful to the women in Koppal and their families, as well as the doctors and staff nurses who participated in our research over many years.
Conflict of Interest: None to declare.
References
- 1.The ADAPTE Collaboration. The ADAPTE Process: The Resource Toolkit for Guideline Adaptation. 2009. [Google Scholar]
- 2.Graham ID, Logan J, Harrison MB, Straus SE, Tetroe J, Caswell W, Robinson N. Lost in knowledge translation: Time for a map? J Contin Educ Health Prof. 2006;26(1):13–24. doi: 10.1002/chp.47. [DOI] [PubMed] [Google Scholar]
- 3.World Health Organization. WHO Handbook for Guideline Development. 2nd, ed. Geneva, Switzerland: WHO; 2014. [Google Scholar]
- 4.WHO. WHO Handbook for Guideline Development. Geneva, Switzerland: WHO; 2012. [Google Scholar]
- 5.Puchalski R L, Khan S, Moore JE, Timmings C, van Lettow M, Vogel JP, et al. Low- and middle-income countries face many common barriers to implementation of maternal health evidence products. J Clin Epidemiol. 2016;76:229–37. doi: 10.1016/j.jclinepi.2016.02.017. [DOI] [PubMed] [Google Scholar]
- 6.GenderHealth Equity Project. Identifying and Addressing Maternal Risks: A Handbook for Healthcare Providers. Bangalore, India: Indian Institute of Management Bangalore; 2015. [Google Scholar]
- 7.George A, Iyer A, Sen G. Gendered Health Systems Biased Against Maternal Survival: Preliminary Findings from Koppal, Karnataka, India. Brighton, Sussex, UK: Institute of Development Studies; IDS Working Paper 253.
- 8.Shankar M, Reddy B. Anaemia in pregnancy still a major cause of morbidity and mortality: Insights from Koppal district, Karnataka, India. Reprod Health Matters. 2012;20(40):67–68. doi: 10.1016/S0968-8080(12)40669-3. [DOI] [PubMed] [Google Scholar]
- 9.Iyer A, Sen G, Sreevathsa A, Varadan V. Verbal autopsies of maternal deaths in Koppal, Karnataka: Lessons from the grave. BMC Proc. 2012;6(Suppl1):P2. doi: 10.1186/1753-6561-6-S1-P2. [DOI] [Google Scholar]
- 10.Shankar M, Srinidhi V. December 14, 2013; Deconstructing clinical knowledge of obstetric care at the primary level: Insights from rural Karnataka, India; Singapore: National University of Singapore; 2013. [Google Scholar]
- 11.Maternal Health Division. Guidelines for Pregnancy Care and Management of Common Obstetric Complications by Medical Officers. New Delhi, India: Department of Family Welfare, Ministry of Health & Family Welfare, Government of India; 2005. [Google Scholar]
- 12.Maternal Health Division. Trainees’ Handbook for Training of Medical Officers in Pregnancy Care and Management ofCommon Obstetric Complications. New Delhi, India: Department of Family Welfare, Ministry of Health & Family Welfare, Government of India; 2009. [Google Scholar]
- 13.Maternal Health Division. Workbook for Training ofMedical Officers in Pregnancy Care and Management of Common Obstetric Complications. New Delhi, India: Department of Family Welfare, Ministry of Health & Family Welfare, Government of India; 2009. [Google Scholar]
- 14.WHO. Pregnancy, Childbirth, Postpartum and Newborn Care: A Guide for Essential Practice. Geneva, Switzerland: WHO; 2003. [PubMed] [Google Scholar]
- 15.WHO . Managing Complications in Pregnancy and Child Birth: A Guide for Midwives and Doctors. Geneva, Switzerland: WHO; 2007. UNFPA, UNICEF, World Bank. [Google Scholar]