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Table 1 Examples of implementation considerations influenced by qualitative findings

From: Qualitative Evidence Synthesis (QES) for Guidelines: Paper 3 – Using qualitative evidence syntheses to develop implementation considerations and inform implementation processes

Example Qualitative evidence synthesis (QES) finding/s   Other considerations/sources of information Implementation considerationsa
1 RECOMMENDATION: Midwife-led continuity-of-care (MLCC) models, in which a known midwife or small group of known midwives supports a woman throughout the antenatal, intrapartum and postnatal continuum, are recommended for pregnant women in settings with well-functioning midwifery programmes [14]
From QES about factors affecting uptake and quality of routine antenatal care services [19]:
Women appreciated being seen by the same healthcare professional at each appointment (including pre and post-natal) primarily because this gave them the opportunity to build caring, trusting relationships with healthcare providers (high confidence in the evidence).
  Additional information from the same QES and input from the guideline panel suggested that the lack of trained midwives and the potential for health professional burnout from work overload often reduced the feasibility of this model of care. Need to know:
what model of care is currently being used; whether there are sufficient numbers of trained midwives; and whether resources are available or can be shifted to facilitate this model.
Need to have: a well-functioning midwifery programme.
Need to do: consult all relevant stakeholders, including human resource departments and professional bodies; assess the need for additional training in MLCC; ensure that there is a well-functioning referral system in place; and monitor midwife workload and burnout.
Need to consider: strategies to scale-up the quality and number of practising midwives; ways of providing continuity-of-care through other care providers, e.g. lay health workers (LHWs); and whether a caseload or team MLCC model is more appropriate.
2 RECOMMENDATION: Epidural analgesia is recommended for healthy pregnant women requesting pain relief during labour, depending on a woman’s preferences [15]
From QES on experiences of labour and childbirth [20]:
... there were mixed views of epidural analgesia usage. Views were influenced by the availability of epidural analgesia, and by accounts of others (moderate confidence in the evidence). Some women expressed an a priori desire for an epidural analgesia to help with a pain-free labour, to alleviate a fear of pain and/or to remain in control during labour (moderate confidence in the evidence), while others requested an epidural as a last resort, when the level of pain and/or sense of control over the labour was overwhelming and unmanageable (low confidence in the evidence).
A perceived lack of effectiveness of epidural analgesia use reported by women in some studies was partly attributed to late administration (low confidence in the evidence), suggesting that there might be logistical issues in implementing this pain relief method.
  All of the findings on epidural use came from high-income country settings where epidural analgesia is widely available. In lower-resource settings, where it is not so widely used, there are likely to be financial implications as well as additional training considerations, which may negatively impact on the feasibility of implementing this intervention. Evidence on the resources required for this intervention were also considered by the panel. Policy-makers need to determine which pain relief measures are most feasible and acceptable in their settings.
Facilities offering epidural analgesia need to have staff with the appropriate specialist skills (anaesthetists, obstetricians), as well as equipment and systems in place to monitor, detect and manage any undesirable effects of the procedure during and after labour to ensure the safety of mother and baby. Epidural analgesia should not be introduced in settings where these resources are not consistently available.
3 General implementation considerations from “Guidance on communication interventions to inform and educate caregivers on routine childhood vaccination in the African Region” (under review)
From QES about perceptions of childhood vaccination information [21]:
Parents generally find the amount of vaccination information they are currently receiving to be inadequate (high confidence). They find some of this information to be too general and want specific information on:
the benefits of different vaccines as well as possible side effects
• how vaccines are made and how they work
• the diseases the vaccines are designed to prevent
• the differences between different vaccines
• the vaccination schedule and what to expect at the vaccine appointment (high confidence)
   Different people are likely to have different information needs. However, all people should have easy access to information about the benefits of different vaccines as well as possible side effects; how vaccines are made and how they work; the diseases the vaccines are designed to prevent; the differences between different vaccines; the vaccination schedule; and what to expect at the vaccine appointment.
4 RECOMMENDATION: We recommend the use of LHWs to provide continuous support during labour, in the presence of a skilled birth attendant. However, appropriate attention must be paid to the acceptability of the intervention to other healthcare providers [5]
From QES about the implementation of lay health worker programmes [7]:
Activities that demand that the LHW is present at specific times, for instance during labour and birth, lead to irregular and unpredictable working conditions. This may have direct implications for LHWs’ expectations regarding incentives (low certainty evidence). LHWs may also be concerned about personal safety when working in the community and some LHWs were reluctant to visit clients at night because of safety issues (moderate certainty evidence).
   Systems need to be in place to support LHWs who may need to travel at night in order to assist during labour and delivery.
5 General implementation considerations from “Guidance on communication interventions to inform and educate caregivers on routine childhood vaccination in the African Region)” (under review)
From QES about perceptions of childhood vaccination information [21]:
People’s trust in and relationship with the information source: parents find it difficult to know which vaccination information sources to trust and to find a source that they perceive as impartial or balanced. They feel that the information they receive is biased towards vaccination (high confidence). Some parents distrust or lack confidence in information sources linked to the government. They consider these sources to be biased, to be withholding information, or to be motivated by financial gain (moderate confidence).
Health workers are an important source of vaccination information for many parents (high confidence). Some parents vaccinate their children because they perceive their health workers as trustworthy and helpful (moderate confidence). However, some parents feel rushed and intimidated into vaccinating, or judged and pressured by health workers (moderate confidence). Some parents, especially vaccine-hesitant parents, also question whether health workers’ motives are tied to financial gain (moderate confidence). Parents who have less trust in their health worker or the information they provide, may search for more information from other sources (low confidence).
Politicians’ opinions and actions regarding personal vaccination choices may also influence parents’ perceptions of vaccination (low confidence).
  Knowledge and expertise from within the guideline panel and the technical team. Community members should feel confident that health workers and others communicating vaccination information are driven primarily by the best interests of the child and are trustworthy, balanced and impartial. Consider involving LHWs or other members of the community, including religious or political leaders, if these are viewed by communities as trustworthy sources.
6 RECOMMENDATION: Respectful maternity care (RMC), which refers to care organised for and provided to all women in a manner that maintains their dignity, privacy and confidentiality, ensures freedom from harm and mistreatment, and enables informed choice and continuous support during labour and childbirth, is recommended [15]
From QES on RMC [22]:
Findings from a qualitative review indicate that women appreciate RMC across countries and settings (high confidence in the evidence). Stakeholders (including women, providers and administrators) emphasised the theoretical importance of providing and ensuring RMC for all women. Review findings also suggest that efforts to address or improve RMC may be acceptable to healthcare providers (high confidence in the evidence). However, in environments where resources are limited, healthcare providers believe that RMC could increase their workload and could reduce their ability to provide quality care to all women.
  The WHO’s normative position and the UNHRC’s report on a rights-based approach to maternal health strongly influenced the guideline panel and technical team [23].
Individual studies suggested that mistreatment of women during childbirth is often due to existing social norms and, in some settings, it may be regarded by healthcare providers and other stakeholders as acceptable [22, 24].
Mechanisms should be put in place to ensure that all women, and particularly those from disadvantaged backgrounds, are made aware of (1) their right to RMC and (2) the existence of a mechanism for raising and addressing complaints (e.g. an audit and feedback mechanism that integrates women’s complaints and ensures that responses are provided)
  1. aIn most instances, these implementation considerations are excerpts from the respective guidelines and readers are encouraged to refer to the respective guidelines for other related implementation considerations