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

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

ComponentDescription
1. Baseline Assessment Tool (BAT)The BAT consists of a Microsoft Excel file which includes sub-components a–c.
a. Situational Analysis ToolThe situational analysis tool tab serves as a data collection guide and is loosely adapted from the WHO health system building blocks [15, 16]. Questions (soliciting mostly dichotomous yes/no or numerical responses) are grouped as follows:
 (1) Leadership and governance
 (2) Health information systems
 (3) Services delivery
 (4) Health workforce
 (5) Financing
 (6) Access to essential medicines
 (7) Patient and population engagement
 (8) Existing ANC model.
Information from section (b) of the tab sets population parameters establishing which context-specific recommendations should be applied or not. The entirety of the results from this exercise are then summarised in a narrative report, which also highlights challenges and promising initiatives supporting the implementation of the country’s current ANC model.
b. Recommendations Mapping ExerciseThis tab assists users to map the country’s existing ANC policies to the WHO ANC recommendations. It also provides users with a link between the population parameters and the recommendations that apply (or not) to the country setting. Users are asked to compare how current activities (and related policies) align with each of the 49 ANC recommendations, who performs said activity (main ANC provider or other), and whether a national policy change or update is necessary. Additionally, the Ministry of Health programme manager responsible for said change should be identified, as well as a timeline for the update to take place.
c. Country-specific ANC package (Output 1) and Strengths, Weaknesses, Opportunities and Threats (SWOT) analysis for implementation of new or update ANC recommendations (Output 2)The country-specific ANC package (Output 1) is an output in which all recommended ANC activities to be implemented during each of the eight contacts are outlined. The activities are broken down into three categories that emerged from a scoping review [17] on what women want from ANC care, namely information, medical interventions and interpersonal support. This output also outlines which healthcare cadre provides each activity, the level of the health system at which the intervention will be provided, and the phasing, if necessary, to scale up that activity (i.e. the country may decide to phase the implementation of the ultrasound recommendation to procure equipment, train staff, etc.)
Output 2 consists of a SWOT analysis. In the version that was user tested, the SWOT analysis focused on innovations that could assist the country’s implementation of the ANC package. Innovations were drawn from the health system-related recommendations in the ANC Guideline (section E) as well as existing national initiatives or local pilot programmes with potential for scale up. However, based on stakeholder feedback, we have modified the SWOT analysis to respond to new and updated recommendations that the country will implement.
2. Qualitative Evidence Synthesis (QES) Slidedoc®This PowerPoint, built using Duarte Slidedoc® format, details how the QES were employed, not only to inform the ANC recommendations (regarding values and acceptability) but also in shaping the entire guideline development process and explaining the focus on a ‘positive pregnancy experience’. An abbreviated version of the Slidedoc® was used during the stakeholder meetings, after a brief presentation on the overall guideline, to set the tone of the meeting.
Supplementary materials:
 a. Implementation considerations
 b. Remarks section from each recommendation
 c. National ANC guideline template
 d. Draft agenda for stakeholder meeting
 e. Draft group work materials for stakeholder meeting
Following user testing feedback, all supplementary materials were moved to the instruction manual (Additional file 3). These materials contain the implementation considerations and the remarks section from each recommendation, which were extracted verbatim from the WHO ANC Recommendations [1]. They aim to help toolkit users develop Outputs 1 and 2.
The draft template is aimed at guiding countries in their development of an updated ANC policy (after completing the mapping), which should align with the longer-term national reproductive health strategy.
The supplementary materials (draft agenda and draft group work materials) aim to help the MoH organise and carry out the stakeholder meeting.
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