Barriers, Facilitators and Priorities for Implementation of WHO Maternal and Perinatal Health Guidelines in Four Lower-Income Countries: A GREAT Network Research Activity.
BACKGROUND
Health systems often fail to use evidence in clinical practice. In maternal and perinatal health, the majority of maternal, fetal and newborn mortality is preventable through implementing effective interventions. To meet this challenge, WHO's Department of Reproductive Health and Research partnered with the Knowledge Translation Program at St. Michael's Hospital (SMH), University of Toronto, Canada to establish a collaboration on knowledge translation (KT) in maternal and perinatal health, called the GREAT Network (Guideline-driven, Research priorities, Evidence synthesis, Application of evidence, and Transfer of knowledge). We applied a systematic approach incorporating evidence and theory to identifying barriers and facilitators to implementation of WHO maternal heath recommendations in four lower-income countries and to identifying implementation strategies to address these.


METHODS
We conducted a mixed-methods study in Myanmar, Uganda, Tanzania and Ethiopia. In each country, stakeholder surveys, focus group discussions and prioritization exercises were used, involving multiple groups of health system stakeholders (including administrators, policymakers, NGOs, professional associations, frontline healthcare providers and researchers).


RESULTS
Despite differences in guideline priorities and contexts, barriers identified across countries were often similar. Health system level factors, including health workforce shortages, and need for strengthened drug and equipment procurement, distribution and management systems, were consistently highlighted as limiting the capacity of providers to deliver high-quality care. Evidence-based health policies to support implementation, and improve the knowledge and skills of healthcare providers were also identified. Stakeholders identified a range of tailored strategies to address local barriers and leverage facilitators.


CONCLUSIONS
This approach to identifying barriers, facilitators and potential strategies for improving implementation proved feasible in these four lower-income country settings. Further evaluation of the impact of implementing these strategies is needed.
UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Reproductive Health and Research, World Health Organization, Headquarters, Geneva, Switzerland.
Joshua P
JP
Vogel
Knowledge Translation Program, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada.
Julia E
JE
Moore
Knowledge Translation Program, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada.
Caitlyn
C
Timmings
Knowledge Translation Program, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada.
Sobia
S
Khan
UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Reproductive Health and Research, World Health Organization, Headquarters, Geneva, Switzerland.
Dina N
DN
Khan
Health System and Reproductive Health Research Directorate, Ethiopian Public Health Institute, Addis Ababa, Ethiopia.
Atkure
A
Defar
WHO Country Office, Addis Ababa, Ethiopia.
Azmach
A
Hadush
Maternal and Child Health Directorate, Ministry of Health, Addis Ababa, Ethiopia.
Marta
M
Minwyelet Terefe
WHO Country Office, Addis Ababa, Ethiopia.
Luwam
L
Teshome
Independent consultant, Yangon, Myanmar.
Katherine
K
Ba-Thike
Burnet Institute, Melbourne, Australia.|Department of Medicine, The University of Melbourne, Melbourne, Victoria, Australia.
Kyu Kyu
KK
Than
Ministry of Health, Community Development, Gender, Elderly and Children, Dar-es-Salaam, United Republic of Tanzania.
Ahmad
A
Makuwani
Ifakara Health Institute, Dar-es-Salaam, United Republic of Tanzania.
Godfrey
G
Mbaruku
Ifakara Health Institute, Dar-es-Salaam, United Republic of Tanzania.
Mwifadhi
M
Mrisho
Makerere University, Kampala, Uganda.
Kidza Yvonne
KY
Mugerwa
Knowledge Translation Program, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada.|Department of Emergency Medicine, University Health Network, Toronto, Canada.
Lisa M
LM
Puchalski Ritchie
Knowledge Translation Program, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada.
Shusmita
S
Rashid
Knowledge Translation Program, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada.
Sharon E
SE
Straus
UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Reproductive Health and Research, World Health Organization, Headquarters, Geneva, Switzerland.
A Metin
AM
Gülmezoglu
D003906:Developing Countries; D005002:Ethiopia; D005260:Female; D017144:Focus Groups; D006284:Health Plan Implementation; D006287:Health Planning Guidelines; D006801:Humans; D007231:Infant, Newborn; D008427:Maternal Health Services; D002052:Myanmar; D018743:Perinatal Care; D011203:Poverty; D011247:Pregnancy; D036301:Qualitative Research; D012106:Research; D011795:Surveys and Questionnaires; D013636:Tanzania; D057170:Translational Research, Biomedical; D014454:Uganda; D014944:World Health Organization