title: 'How to know what you need to do': a cross-country comparison of maternal health guidelines in Burkina Faso, Ghana and Tanzania.
abstract: BACKGROUND
  Initiatives to raise the quality of care provided to mothers need to be given priority in Sub Saharan Africa (SSA). The promotion of clinical practice guidelines (CPGs) is a common strategy, but their implementation is often challenging, limiting their potential impact. Through a cross-country perspective, this study explored CPGs for maternal health in Burkina Faso, Ghana, and Tanzania. The objectives were to compare factors related to CPG use including their content compared with World Health Organization (WHO) guidelines, their format, and their development processes. Perceptions of their availability and use in practice were also explored. The overall purpose was to further the understanding of how to increase CPGs' potential to improve quality of care for mothers in SSA.
  
  
  METHODS
  The study was a multiple case study design consisting of cross-country comparisons using document review and key informant interviews. A conceptual framework to aid analysis and discussion of results was developed, including selected domains related to guidelines' implementability and use by health workers in practice in terms of usability, applicability, and adaptability.
  
  
  RESULTS
  The study revealed few significant differences in content between the national guidelines for maternal health and WHO recommendations. There were, however, marked variations in the format of CPGs between the three countries. Apart from the Ghanaian and one of the Tanzanian CPGs, the levels of both usability and applicability were assessed as low or medium. In all three countries, the use of CPGs by health workers in practice was perceived to be limited.
  
  
  CONCLUSIONS
  Our cross-country study suggests that it is not poor quality of content or lack of evidence base that constitute the major barrier for CPGs to positively impact on quality improvement in maternal care in SSA. It rather emphasises the need to prioritise the format of guidelines to increase their usability and applicability and to consider these attributes together with implementation strategies as integral to their development processes.
authors.affiliation: Department of Public Health Sciences, Division of Global Health (IHCAR), Karolinska Institutet, Nobels väg 9, SE-17177 Stockholm, Sweden. ulrika.baker@ki.se
authors.forename: Ulrika
authors.initials: U
authors.lastname: Baker
authors.forename: Göran
authors.initials: G
authors.lastname: Tomson
authors.forename: Mathias
authors.initials: M
authors.lastname: Somé
authors.forename: Bocar
authors.initials: B
authors.lastname: Kouyaté
authors.forename: John
authors.initials: J
authors.lastname: Williams
authors.forename: Rose
authors.initials: R
authors.lastname: Mpembeni
authors.forename: Siriel
authors.initials: S
authors.lastname: Massawe
authors.forename: Antje
authors.initials: A
authors.lastname: Blank
authors.forename: Lars L
authors.initials: LL
authors.lastname: Gustafsson
authors.forename: Jaran
authors.initials: J
authors.lastname: Eriksen
mesh_terms: D002050:Burkina Faso; D003695:Delivery of Health Care / Q000379:methods; D019317:Evidence-Based Medicine / Q000592:standards; D005260:Female; D005869:Ghana; D019983:Guideline Adherence; D006801:Humans; D008429:Maternal Welfare; D017063:Outcome Assessment, Health Care; D017410:Practice Guidelines as Topic; D011247:Pregnancy; D036301:Qualitative Research; D013636:Tanzania; D014944:World Health Organization