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

Abstract

Background Obstetric guidelines are useful to improve the quality of care. Availability of international guidelines has rapidly increased, however the contextualization to enhance feasibility of implementation in health facilities in low and middle-income settings has only been described in literature in a few instances. This study describes the approach and lessons learned from the ‘bottom-up’ development process of context-tailored national obstetric guidelines in middle-income country Suriname. Methods Local obstetric health care providers initiated the guideline development process in Suriname in August 2016 for two common obstetric conditions: hypertensive disorders of pregnancy (HDP) and post partum haemorrhage (PPH). Results The process consisted of six steps: (1) determination of how and why women died, (2) interviews and observations of local clinical practice, (3) review of international guidelines, (4) development of a primary set of guidelines, (5) initiation of a national discussion on the guidelines content and (6) establishment of the final guidelines based on consensus. Maternal enquiry of HDP- and PPH-related maternal deaths revealed substandard care in 90 and 95% of cases, respectively. An assessment of the management through interviews and labour observations identified gaps in quality of the provided care and large discrepancies in the management of HDP and PPH between the hospitals. International recommendations were considered unfeasible and were inconsistent when compared to each other. Local health care providers and stakeholders convened to create national context-tailored guidelines based on adapted international recommendations. The guidelines were developed within four months and locally implemented. Conclusion Development of national context-tailored guidelines is achievable in a middle-income country when using a ‘bottom-up’ approach that involves all obstetric health care providers and stakeholders in the earliest phase. We hope the descriptive process of guideline development is helpful for other countries in need of nationwide guidelines.

Postpartum hemorrhage in Suriname: A national descriptive study of hospital births and an audit of case management

“…In the case of estimated high blood loss, blood in the bedpan was measured with a measuring jug (mL) or the pads were weighted (grams = mL). However, in two hospitals, only blood clots were measured [18]. Hospital administrative personnel anonymously entered data from the paper parturition books into a password-secured digital database on a daily basis.…”

“…The criteria-based audit was confined to severe PPH. Prevention and management of severe PPH were audited using the national PPH guideline [18]. Detailed information on the cause, course, and management of severe PPH was not always available (S2 Fig in S1 File).…”

“…Following the designation of Suriname as one of 10 priority countries for reducing maternal mortality, PAHO implemented this project in Suriname in 2018 [25]. In Suriname, efforts to reduce preventable maternal deaths from PPH resulted in national PPH guideline development and obstetric emergency training in 2016 and 2019 [18,26].…”

“…Delays in diagnosis, monitoring, and treatment were critical factors contributing to these deaths [17]. A national PPH guideline developed in 2016 incorporates international recommendations for prevention (screening for and treating anemia and active management of the third stage of labor (AMTSL)), early recognition (measurement or visual estimation of the amount of blood loss and clinical signs), and management (oxytocin prevention and therapy and tranexamic acid use) [18]. However, no detailed information on PPH prevalence, causes, and risk indicators were available for Suriname.…”

From Passive Surveillance to Response: Suriname's Steady Efforts to Implement Maternal Death Surveillance and Response (MDSR)

“…4). The "bottom-up" guideline development of the most important causes of maternal deaths, postpartum hemorrhage (PPH), and hypertensive disorders of pregnancy (HDP), was completed in November 2016 [32]. Non-Pneumatic Anti Shock garments were provided by PAHO, followed by training in 2018 and 2019 to reduce and treat PPH.…”