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Development of the WHO Antenatal Care Recommendations Adaptation Toolkit: a standardised approach for countries



Increasingly, WHO recommendations are defined by context-specific factors and WHO is developing strategies to ensure that recommendations are successfully adapted and implemented at country level. This manuscript describes the development of a toolkit to support governments to adapt the WHO recommendations on antenatal care (ANC) for a positive pregnancy experience for their context in a systematic manner.


The toolkit was developed in three steps. It was created with input from methodologists and regional implementation experts (Step 1) followed by a user-testing phase (Step 2), implemented during country stakeholder meetings. User testing consisted of stakeholder interviews that were transcribed, and data was categorised according to the content analysis method. Suggestions for toolkit improvement and issues identified during the interviews were assessed as serious, moderately serious or minor/cosmetic.


A total of 22 stakeholders – comprising five Ministry of Health (MoH) consultants, four MoH policy-makers, and 13 advisors/implementers – from Burkina Faso, India, Rwanda and Zambia participated in user-testing interviews during stakeholder meetings held in each country between August 2018 and February 2019. Most stakeholders had a medical or nursing background and half were women. Overall, responses to the toolkit were positive, with all stakeholders finding it useful and desirable. User testing interviews highlighted four serious, four moderately serious and five minor/cosmetic issues to be managed. These were addressed in the final step (Step 3), an updated version of the WHO ANC Recommendations Adaptation Toolkit, comprised of two main components – a baseline assessment tool with spreadsheets for data entry and a Slidedoc®, a dual-purpose document for reading and presentation, outlining the qualitative data that shaped the women-centred perspective of the guidelines, accompanied by an instruction manual detailing the components’ use.


The WHO ANC Recommendations Adaptation Toolkit was developed to support countries to systematically adapt the WHO ANC recommendations for country contexts. Using this approach, similar tools can be developed to support guideline implementation across different health domains and the continuum of care.

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Improving health is key to reaching the United Nations Sustainable Development Goals. Assisting countries in overcoming common barriers to implementing WHO’s evidence-based guidelines across all health domains will be crucial in achieving the Sustainable Development Goals. To address the complex and diverse global healthcare needs, WHO recommendations are becoming increasingly context specific [1, 2] and context-specific recommendations require additional steps to interpret and apply [3]. Furthermore, passive approaches to dissemination of WHO guidelines, such as printing and distribution, have in the past been criticised for being insufficient [4].

As part of its efforts to improve maternal health and service quality, the WHO launched its comprehensive guideline on routine antenatal care (ANC) for pregnant women and adolescent girls, in November 2016 [1]. The WHO recommendations on ANC for a posiive pregnancy experience are subdivided into five different content categories (nutritional interventions, maternal and fetal assessment, preventive measures, physiological symptoms, and health systems) and seek to integrate service provision across health domains (malaria, tuberculosis, HIV, syphilis, etc.). The guideline includes 23 context-specific recommendations to be tailored to populations with, for example, certain nutritional needs, endemic infections or healthcare settings [5, 6].

Following publication of the ANC guidelines, WHO received requests from national governments for adaptation and implementation support, especially on how to contextualise and tailor the guideline content to local settings. In many countries, such support is critical to ensure WHO guideline uptake at national and subnational levels. In response to goverments' request, and given the complexity of the new 8-contact ANC model outlined by the new recommendations [5, 6], and the known barriers to implementing guidelines at the country level [7], WHO planned to develop tools to support the adaptation and implementation of the ANC recommendations.

This manuscript documents the process of developing a toolkit designed to assist national governments to systematically (1) adapt the ANC guideline to their contexts and (2) update their ANC policies according to the WHO ANC recommendations. The toolkit’s aim is to facilitate the design of country-specific packages for ANC health services, including essential clinical (i.e. blood pressure, weight and height measurement, etc.) and counselling practices (i.e. birth preparedness, labour companion, etc.), tailored to the individual country’s health system and context. It also aims to highlight country-specific factors that are likely to influence (positively or negatively) the implementation of the stakeholder-approved package as well as what should be considered during the country implementation. The described in this manuscript are part of a wider approach to assist countries in translating and tailoring WHO recommendations to national contexts and settings. The example detailed in this manuscript focuses on ANC; however, the methodologies outlined in this manuscript can be applied to any health domain.


The WHO Antenatal Care Recommendations Adaptation Toolkit was created in a three-step process (Fig. 1). Firstly, in Step 1, the toolkit development team (hereafter referred to as ‘the team’) created the draft toolkit. Whilst in Step 2, the team user tested the toolkit in four countries, Burkina Faso, India (two states: Assam and Tamil Nadu), Rwanda and Zambia, during national (or state-level in India) adaptation processes of the WHO ANC recommendations which employed the toolkit. Finally, in Step 3, the team updated the toolkit, based on feedback from the user testing results, and developed an instruction manual describing its use for country adaptation of the WHO ANC recommendations.

Fig. 1
figure 1

Toolkit development methodology and timeline

Step 1: Toolkit creation for WHO ANC recommendations

In response to government requests, the idea for the development of a WHO ANC toolkit focusing on policy-makers originated in August 2017 during a meeting in Norway with research methodologists and knowledge translation experts, who had worked on the development of the WHO ANC guideline.

Prior to the first drafting of the components, the team consulted with relevant experts during the WHO’s Sexual and Reproductive Health Department’s Scientific and Technical Advisory Group annual meeting in February 2018 for similar tools employed in knowledge translation efforts as well as in other health domains. In drafting the toolkit’s Baseline Assessment Tool (BAT) component, the team modelled it on similar tools developed by the United Kingdom’s National Institute for Health and Care Excellence (NICE) [8, 9]. Additionally, the team drew on the work of the WHO’s Evidence-Informed Policy Network (EVIPNet) for designing the toolkit's implentation and the stakeholder meetings' organisation [10].

The first outline and subsequent draft versions of the toolkit were developed by ÖT, TAL and MBa. The toolkit was then further refined in collaboration with WHO headquarters, regional and country office colleagues (including NK, FT and MBu) during a March 2018 meeting in Lusaka, Zambia. Subsequently, in April, a second version of the tool was reviewed by the methodologists and experts (from the original Norway meeting) and it was decided that a second informational component on the Qualitative Evidence Synthesis (QES), which underpinned the ANC recommendations would be added to the toolkit in the form of a Slidedoc®; thereafter, during user testing, the two components together were referred to as the WHO ANC policy-maker toolkit [11]. The toolkit was also shared with WHO headquarters staff with expertise in maternal and child health for further feedback.

Step 2: Toolkit user-testing during country adaptation process

In parallel to the tool development process, WHO has been directly working with four countries, Burkina Faso, India (in two states: Assam and Tamil Nadu), Rwanda and Zambia, to update their ANC policies based on the 2016 WHO recommendations. To do so, the four countries employed the toolkit for conducting a situational analysis of current ANC service delivery, held stakeholder consultations, and updated and validated national ANC policy changes. Stakeholder meetings were organised by the Ministry of Health (MoH) in each of the four countries to assess and update the national ANC policy, where this toolkit was used to inform the proceeding. In preparation for use in Burkina Faso, the toolkit was translated into French. This country guideline adaptation process, where the toolkit was applied, created an opportunity to user-test the toolkit with the goal of improving it and making it more useful and user friendly. The toolkit user-testing process comprised a survey of the views and experiences of users through individual stakeholder interviews. The survey was modelled after user testing efforts carried out previously by Norwegian Public Health Institute [12, 13]. Those interviewed were exposed to all or part of the toolkit either prior to or during the stakeholder meetings. Potential user-testing stakeholders were identified by members of the team, WHO country staff, or the country consultant who supported the process, to ensure that all relevant users of the toolkit would be represented in the findings. Stakeholders who were invited to take part in the user-testing provided written informed consent.

The standardised interview guide used was adapted from a guide employed in user-testing of the DECIDE framework [14], and included open-ended questions on the usefulness, user-friendliness, credibility and desirability of the toolkit. User-testing interviews were conducted during coffee and lunch breaks, or immediately after concluding the stakeholder’s meetings, in a 30- to 60-min process. Each interview was conducted by an interviewer (MBa or TAL) and accompanied by an observer/notetaker (MBa, TAL, NK, FT or RC) with an in-depth knowledge of the toolkit. In addition to toolkit-related questions, interviewed stakeholders were invited to comment on the usefulness and value of the stakeholder meeting. The project was reviewed and approved by the UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction’s research project review panel.

All interviews were transcribed and checked (by TAL and MBa) and data from Burkina Faso were translated to English. Following this, TAL and MBa categorised and coded the data using content analysis methods, and employed a pre-defined framework. The framework grouped data according to problems identified, positive feedback, and suggestions for improvement. ‘Problems identified’ were further categorised into three groups, namely (1) serious issues, (2) moderately serious issues or big frustrations, and (3) minor or cosmetic issues. Categorisation into these three sub-groups was done subjectively by TAL and MBa (criteria were not developed, instead shared experience and understanding of the toolkit served as a basis for this step). Differences were resolved by discussion or by involving a third author (OT). Common themes with respect to problems and suggestions related to the different toolkit components were tabulated; thereafter, the team considered how best to address them. Participant comments and suggestions concerning the stakeholder meetings were also considered.


As a result of Step 1, the team created a draft version of the WHO ANC Recommendations Adaptation Toolkit. During Step 2, the team led the user testing of the draft version within the context of country implementation. The findings from the user testing process and the resulting updated version of the toolkit (Step 3), including a user’s manual describing how to employ it to inform country adaptation processes, are detailed in this section.

Step 2: Toolkit user-testing during country adaptation process

For the user testing of the ANC toolkit, 22 stakeholders from Burkina Faso (n = 4), India (n = 7), Rwanda (n = 6) and Zambia (n = 5) participated and provided feedback. User-testing stakeholders fell into three categories, namely consultants who had completed the situational analyses and draft country reports (n = 5), MoH policy-makers (n = 4), and advisors and other stakeholders (n = 13). Most stakeholders (17/22) had a medical background, i.e. either held a medical degree or a nursing or midwifery qualification. There was equal distribution between male and female stakeholders across the sample. Most interviews were conducted in English (n = 17), the remaining five were conducted in French (four in Burkina Faso and an interview in Rwanda, which was conducted in English and interpreted to French for the participant).

Baseline Assessment Tool (BAT) user-testing results

User feedback from the consultants

The country consultants were the stakeholders with the greatest exposure to the toolkit, having received it at least 6 weeks prior to the stakeholder meetings and having used it to compile the draft country reports for discussion at the meetings. All five consultants stated that they were familiar with these types of toolkits. However, most expressed that the BAT component of the toolkit was more detailed than usual, and their first impressions suggested that it was rather intimidating. For example, comments included “A lot of sheets!”; “ first, I thought I wouldn’t master the guideline in any way, it would take a long time...”; “I thought what have I gotten myself into! [laugh] I found it voluminous and complex.”

Only one of the consultants stated positively that their first impression was a “wow impression”. For the others, their responses suggested that it was only after working with the BAT that they appreciated that the level of detail required facilitated a comprehensive understanding of the existing situation of ANC service provision.

  • …as I went on I realised there was more to the tool...

  • First it was overwhelming, then understandable that each [item in the BAT] shows the total picture.”

  • “[It is] comprehensive and good; the recommendations tab gives an idea of how we are performing.”

  • “[It is] an informative excel sheet with so many areas that were helpful to understand what is happening with the programmes running.”

  • The [Excel] sheets were very useful and helped make the report.”

The time taken for consultants to complete the situational analysis ranged from 2 to 4 weeks. Consultants explained that this was because:

  • It took me one week to understand it fully [before I could start to complete it]. One week is necessary.”

  • fill it out I really needed reliable sources.”

  • It took time to coordinate with MoH people.”

  • Finding people to sit with and ask questions took time, because they were mostly out of town.”

Consistent with their initial impressions, three of the five consultants found the BAT quite onerous to complete due to the level of detail required, whereas the other two did not, for example, stating that the spreadsheet had “...good linkages, is easy to use, and flows logically”. However, all consultants unanimously agreed that it was a useful tool, partly due to its detail:

  • It help[sic] to clearly inform what needs to be done so as not to miss anything.”

  • It is probably something that should be done every so often so that you are improving on service delivery.”

User feedback from the policy-makers

In addition to receiving the draft report compiled by each country consultant, the four MoH policy-makers received the complete toolkit prior to their respective country stakeholder meetings. Most said that they had not read the BAT in detail before the meeting, therefore their exposure to the materials was less than that of the consultants. Initial impressions of the BAT were positive. One policy-maker noted that “They were requesting much information!” All four considered the BAT to be useful because of the detailed outputs it provided:

  • All the information is useful because it goes deeper than the data that the MoH currently has on ANC services.”

  • I expected a few questions regarding key points which were missing [from our existing policy] according to the new guideline, but this one goes deep.”

  • At first, I didn’t think it was necessary, but in the end I realised it was necessary.”

  • It gives the big picture or overview of the programme and touched on many areas not usually thought about, for example, human resources.”

In general, the MoH policy-makers found the toolkit to be a desirable aid for decision-making:

  • There were some recommendations that I was not aware of [and it was helpful for these].”

  • It encompasses many things. We can use it, employ it at different levels of the health system.”

  • This tool has components of things we are doing and components of things that we are not doing. It’s a reminder that if there’s evidence those things work, we jack ourselves up and... implement the areas we are not doing.”

User feedback from advisors and other stakeholders

Most of these stakeholders commented only on the ‘Output’ sheets of the BAT; however, for the Rwanda stakeholder meeting, the toolkit was included with the other pre-meeting documents. Therefore, three of the advisor-type stakeholders in Rwanda also provided feedback on the full BAT. Comments from this group of stakeholders were consistent with the other two groups with respect to the need for clear instructions on how to complete the BAT and, in particular, the meeting group work components (the country-specific ANC package (output 1) and the SWOT analysis (output 2)).

What was notable from this group, in particular, were concerns expressed about the meeting group work outputs not adequately capturing implementer issues:

  • “[In our group] we were not aware of the real challenges on the ground.”

  • “[There were] a lot of ground level issues missing. Data was good to see but challenges and difficulties at ground level need to be discussed at central level.”

  • Some information that was not captured by the tool...why, what is the cause?

Feedback from this group helped to identify certain country-specific interventions that were missing from the BAT (e.g. malaria counselling). This group also had issues with certain terminology used in the toolkit, when it differed from what was used in their settings.

Issues identified with the draft version of the BAT are tabulated in Table 1, alongside the actions taken by the team to address them. Where stakeholders offered suggestions on how to improve the BAT, the team gave these due consideration during the toolkit revision.

Table 1 Issues identified and suggestions offered by stakeholders of the user-testing study

Overall, user testing of the BAT identified four issues that the team assessed as serious (Table 1). One related to the need for clear instructions on how to complete each sheet. Another concerned a technical problem with the conditional formatting linkage between different sheet parameters in the French version. Formatting in general, was a frequent source of user frustrations. Comprising many columns and rows, headings were sometimes lost when scrolling across sheets, making the viewing and understanding of some sections challenging.

The ‘Recommendations’ sheet was a particular source of confusion, and its purpose was often misinterpreted, leading to incomplete or inappropriate data collection. Another problem that the team assessed as serious was the apparent failure of the BAT to identify prevailing equity issues in some countries.

Feedback on qualitative evidence synthesis slide document

Overall, meeting stakeholders trusted the information in the Slidedoc®, found it easy to understand and visually appealing from the graphics and pictures. For example, a graphic depicting an experience of a fictional teenage pregnancy resonated with stakeholders as true and humanising the ANC experience. Most concerns related to the amount of information on the slides and the size of the font, although two stakeholders commented that the logic models at the end of the Slidedoc® were rather complicated. Especially in India, stakeholders wanted more pictures representing the local population and examples representing the country context. Thus, comments from a variety of stakeholders included:

  • “[It] is easy to understand because it has information and images to convey the evidence...

  • I did like the caricatures which present stories and make it easy to helps people understand why WHO has issued these new recommendations.”

  • There was lots of information and the slides had too much information. If you’re not sitting close you cannot read it.”

In assessing the feedback, the team agreed that the issue with the logic models and the amount of information presented in the Slidedoc® was moderately serious; other comments and suggestions were minor or cosmetic. Table 1 shows the respective actions taken to address them.

Feedback on national stakeholder meetings where the toolkit was used

In general, stakeholder liked the meetings and appreciated being included in them. As it was a Ministry-led and WHO-supported process, stakeholders found the toolkit, presentations and process trustworthy and credible. They especially appreciated the representation of diverse stakeholders and felt that this was key to the success of the meeting:

  • We got different views coming from programme managers, health providers, partners – I mean, I think we got information from all categories of stakeholders, which is why it was really helpful – especially from those providing services.”

  • “[The stakeholder meeting] will definitely help to implement the model here, because they tried to involve many stakeholders, especially people who are implementing or supporting the Ministry to do ANC.”

  • So having everyone together, like, you had midwives, you had doctors, policy-makers working together, it was positive.”

In addition, evidence of government support through the presence of the Health Ministers and other senior members of the MoH was important to stakeholders and gave them confidence in the process:

  • The fact that [he] was leading and taking ownership, and he is a senior person in government, that helps, because it also shows that there is commitment.”

  • “[It was good], seeing the involvement of the higher authorities, even the Minister, joining the team, showing everyone that [improving ANC] is supported by the country.”

Conversely, for meetings where stakeholders felt that representation was limited, stakeholders were more likely to be sceptical of achieving a successful outcome:

  • “[We] need more representation from grass roots level.”

  • “[We needed] more comments from basic officers, implementers.”

  • I was a bit scared regarding implementation because the Stakeholders were not truly familiar with the recommendations.”

Whilst the group interactions were highly praised and appreciated by stakeholders, sometimes they did not feel comfortable to voice their opinions:

  • Not all reps [supervisors and district health personnel] participated actively in discussions.”

  • “[There should have been] more interaction and stimulation for them [the quieter ones] to give their ideas.”

The size of the participant groups for the group work sessions consisted of about 20 stakeholders in most instances. This, as well as the space that was available to conduct group work, was raised by some as a barrier to effective discussions:

  • The discussion groups were very big and so, often only a few people were talking.”

  • Groups were very big, it would have been better to split into four. It also would have been good to get another room for the group work.”

Suggestions offered by stakeholders on how to improve the stakeholder meetings are also summarised in Table 1.

Naming the toolkit

The toolkit was provisionally named the ‘WHO ANC policy-maker toolkit’. Stakeholders were asked what they thought about the name and could offer suggestions. It was noted that the toolkit might not be used exclusively by policy-makers, therefore, this term was not favoured. Whilst several stakeholders favoured inclusion of the term ‘positive pregnancy’ in the name, others favoured a simpler title that clearly described its purpose. Hence, after considering all participant comments and suggestions, the final name of the WHO ANC Recommendations Adaptation Toolkit came about.

Step 3: Toolkit updating process

The WHO ANC Recommendations Adaptation Toolkit, accompanying the WHO ANC guideline, comprises two main components: a BAT with spreadsheets for data entry and information (Additional file 1) and a Slidedoc®, a dual-purpose document for reading and presentation, outlining the qualitative data which helped shaped the guideline’s woman-centred perspective (Additional file 2) The toolkit components, as well as their modifications based on user testing, are outlined in Table 2.

Table 2 WHO antenatal care (ANC) Recommendations Adaptation Toolkit components

Furthermore, the toolkit is accompanied by a user-friendly instruction manual (Additional file 3) to guide stakeholders through updating their national ANC policies using the toolkit. It includes detailed instructions on the process to complete the different components of the BAT (Additional file 1). Table 3 outlines the process to use this toolkit effectively as part of the country adaptation and implementation process, whereby, following the use of the toolkit in the initial stakeholder meeting, countries then finalise their updated integrated ANC package and national ANC policy. Next, countries develop an implementation plan (including revised ANC facility registries and user cards and well as coordination for all necessary resources, i.e. staffing, equipment and materials) and a related budget.

Table 3 Process for employing the WHO Antenatal Care (ANC) Recommendations Adaptation Toolkit


The WHO ANC Recommendations Adaptation Toolkit was developed to support countries adapt and implement the 2016 WHO ANC recommendations in a systematic and transparent way. This iterative 3-step approach, which was well received by a variety of stakeholders, could be replicated in other healthcare domains to support effective guideline adaptation and implementation. In alignment with Straus et al.’s knowledge translation framework, the toolkit seeks to both assess barriers in knowledge use and adapt knowledge (from the WHO ANC guideline) to local context [18,19,20]. To receive feedback on the draft toolkit, four countries (Burkina Faso, India, Rwanda and Zambia) employed it and carried out its user testing. The user-testing process involved diverse stakeholders and was extremely valuable in the development and improvement of the toolkit. Interviews highlighted a range of issues, from minor to serious, that could be addressed by the development team before releasing the toolkit for global use.

The development process was iterative and, while the resulting version of the toolkit is presented with this manuscript (Additional files 1, 2, and 3), the team anticipates that further changes will be made to the toolkit as it is employed in other countries and the team receives more feedback from users. For example, under the guidance of WHO regional office, other countries have used this toolkit in their national processes. Boxes 1 and 2 provide examples of this process in Uganda and Sierra Leone, respectively. While user testing data was not systematically collected in Uganda and Sierra Leone, a number of lessons learnt were incorporated, such as the need to update clinical and woman-held tools and facilities registers as well as indicators to align with ANC recommendations.

The creation of an instructor’s manual for toolkit use (Additional file 3) was a direct response to feedback from user testing. Additionally, some sheets in the BAT were originally included as reference material only. However, during teleconferences with consultants to support their completion of the BAT prior to the stakeholder meetings, it became apparent to the team that users were sometimes confused regarding the purpose of these informational sheets. Therefore, in revising the toolkit, seven of these informational sheets were moved to the instruction manual. All sheets in the BAT now require action, whilst all informational material can now be found in the manual. This aims to make the toolkit more user friendly.

It is important to note that prior to and during stakeholder meetings, various stakeholders voiced concern that the situational analysis process had been based on a desk review only, and believed that primary data collection (whether quantitative or qualitative) would be more helpful for identifying relevant barriers to ANC provision. While this is a valid concern, the team did not modify the toolkit to include primary data collection, mainly due to the resource and time implications of this endeavour; the BAT was designed with the ultimate goal of being simple and of minimal cost. In addition, a varied stakeholder representation (professional associations, community-based organisations, women’s groups, etc.) could supplement the information collected in the BAT. However, depending on resources and time availability, countries may want to conduct primary data collection.

In general, stakeholders highly valued relatable references and imagery in the QES Slidedoc®. For example, the presentation included the logic models for women who attend none, partial or full ANC services and this aimed to help stakeholders consider and identify local factors affecting utilisation and provision of ANC services [17]. Whilst the full Slidedoc® comprises 52 slides in total, a smaller slide deck of 25 slides was used for the stakeholder meeting presentation. User-testing suggested that the accessibility of this document would be enhanced by the insertion of photographic images that reflect local populations and culture. Therefore, consultants and organisers should be encouraged to source these and insert them into the Slidedoc®, which is editable as well as local qualitative data to inform and support local adaptation. Sharing the full Slidedoc® with stakeholders before the stakeholder meeting would also be helpful.

As anticipated, stakeholder meetings were more productive when a diverse group of stakeholders, particularly providers and service users, were represented and encouraged to contribute their opinions and experiences to the meeting discussions. Suggestions provided during the user-testing which aimed at optimising stakeholder engagement are also included in the instruction manual.

To assist other countries interested in adapting and implementing WHO’s ANC recommendations and, ultimately, to increase the impact of the recommendations at country level to improve health outcomes, next steps include making the toolkit available to accompany the WHO ANC guideline, developing an online version of the BAT, and modifying it for use at sub-national decision-making and health system levels.

The toolkit’s development is similarly linked to broader efforts to support healthcare providers in implementing the ANC recommendations. WHO has been exploring other ways to improve knowledge translation through digital health and innovation, including digital reference modules. For this, WHO has created the WHO digital ANC Module for healthcare workers, which provides decision support and longitudinal client record systems. The Module represents a digital health intervention in line with WHO guidance [2]. Further, the integrated ANC package (output 1) will allow for the customisation of the digital Module to different country settings.


WHO is committed to providing technical support to ensure countries achieve effective implementation of guidelines. The WHO ANC Recommendations Adaptation Toolkit is a successful example of the organisation’s new approach to active dissemination for adopting new clinical and health systems recommendations, focused on quality of services. The toolkit was employed to support four countries adapt and prepare to implement the 2016 WHO ANC recommendations. User-testing and stakeholder engagement made a valuable contribution to the development process of the toolkit, leading to the production of a more user-friendly and effective product, accompanied by an instruction manual. Furthermore, this toolkit and the approach to its development is informing an overall adaptation and implementation strategy for guidelines across the maternal health continuum. Such tools can be replicated across health domains for effective guideline adaptation and implementation.

Availability of data and materials

All data related to the study have been reported in this manuscript and relevant associated material are included in the supplementary files.



Antenatal care


Baseline Assessment Tool


Ministry of Health


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We would like to thank Simon A. Lewin, Claire Glenton, Triphonie Nkurunziza, Leopold Ouedraogo, Kasonde Mwinga, Soo Downe, Kenneth W Finlayson, Sarai Malumo, Maria Mugabo Mujawamariya, and Souleymane Zan for the initial development of the toolkit and Allisyn Moran, Anayda Portela, and Nathalie Roos for their review of the toolkit. We would like to thank the consultants, interviewed stakeholders and other stakeholders, who attended the stakeholder meetings and contributed to this process, for taking the time to provide feedback.


The authors alone are responsible for the views expressed in this article and they do not necessarily represent the views, decisions or policies of the institutions with which they are affiliated.


The toolkit development work was funded by a grant from the Sanofi Espoir Foundation. The country adaptation process in four countries was funded by a grant from the Bill and Melinda Gates Foundation.

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Authors and Affiliations



MBa, TAL and ÖT led the manuscript writing process with contributions from the other authors. MBa and TAL interviewed stakeholders and transcribed and analysed the data. MBa, FT, NK and RC played the role of observers and notetakers during the interviews. All authors facilitated the stakeholder meetings. NK and FT prepared the country case studies from Uganda and Sierra Leone, respectively. All authors reviewed and approved the final manuscript.

Corresponding author

Correspondence to Maria Barreix.

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All participants provided informed consent.

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The authors declare that they have no competing interests.

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Supplementary information

Additional file 1.

Baseline Assessment Tool (BAT).

Additional file 2. 

Qualitative Evidence Synthesis (QES) Slidedoc®.

Additional file 3.

Instruction Manual for the WHO Antenatal Care Recommendations Adaptation Toolkit.

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Barreix, M., Lawrie, T.A., Kidula, N. et al. Development of the WHO Antenatal Care Recommendations Adaptation Toolkit: a standardised approach for countries. Health Res Policy Sys 18, 70 (2020).

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