A clinical guideline for the Iranian women and newborns in the postpartum period

Abstract

Background

The postpartum is a vital period for women, newborns, spouses, parents, caregivers, and families. Regarding the importance of postpartum care and the lack of comprehensive and up-to-date clinical guidelines in the country of Iran, the postpartum clinical guidelines have been adapted.

Methods

Cultural adaptation was conducted in three stages. In the first stage, the adaptation team was formed and the process was approved. During the second stage, a systematic literature review was conducted using international databases to identify English-language clinical guidelines published within the last 10 years. Out of 17 guidelines and documents initially selected, 5 guidelines meeting the inclusion and exclusion criteria and published within the last 5 years were chosen following a thorough review by the search team. In the secondary selection, the guidelines were investigated by two subject-matter experts based on AGREE II Checklist, and regarding the high evaluation score obtained by the WHO Recommendations on Postnatal Care of the Mother and Newborn (2022), and the National Institute for Health and Care Excellence (NICE,2021) guideline for postnatal care were selected for cultural adaptation. In the third stage, the opinions of experts from all over the country were collected and scored using the Delphi method, and a final guideline was formulated.

Results

The adapted postpartum clinical guideline has offered 56 recommendations. The recommendations are categorized into four major themes including mother care, newborn care, health system and health promotion interventions and post caesarean care.

Conclusion

Applying evidence-based recommendations for the care of mothers and babies in the postpartum period will enhance the health system, promote the provision of care after vaginal and caesarean births, and ensure a positive postnatal experience for mothers, fathers, babies, and families.

Background

The postpartum period is critical for the long-term physical and mental health of mothers and children [1]. Quality care during the early days and weeks after childbirth significantly influences their experiences [2]. During this phase, women adapt to physical, mental, and social changes, which can present significant challenges such as insomnia, fatigue, breastfeeding issues, stress, mental health concerns, reduced sexual desire, and urinary incontinence. [3]. Socio-economic and cultural factors can influence mothers’ experiences, emotions, and behaviors during early motherhood [4]. Additionally, the support and encouragement provided to mothers by healthcare staff during childbirth, in hospital settings, at home, and through peer support can significantly influence their health and well-being [5].

Despite its importance, evidence suggests that postpartum care has been undervalued and under-resourced [6]. Studies indicate that many women are dissatisfied with the postpartum care they receive. For instance, a survey in England revealed that 50% of mothers felt they lacked adequate help, support, and information on newborn feeding [4]. Furthermore, in the United States, 40% of women do not attend their postpartum checkups, leading to challenges in managing chronic conditions, accessing effective contraception, and increasing the risk of short inter-pregnancy intervals and preterm delivery, particularly among disadvantaged communities [7].

In Iran, postpartum care often receives less attention compared to the antenatal period, both in terms of quality and quantity [8]. Research indicates that only 30% of mothers in developing countries receive adequate postpartum care, with approximately 70% expressing dissatisfaction with the care in Iran [9,10,11].

The American College of Obstetricians and Gynecologists advocates for continuous, personalized postpartum care to optimize the health of mothers and newborns, emphasizing that postpartum checkups should not be limited to a single visit at 6–8 weeks after delivery [7]. Similarly, the WHO recommends postpartum care within 24 h after childbirth, followed by at least three additional visits, aiming to improve maternal and newborn health [12].

Postpartum care plays a vital role in continuous care for mothers, newborns, and children, contributing to the achievement of sustainable development goals in reproductive health, such as reducing maternal and infant mortality [13]. However, the lack of attention to maternal health needs during the postpartum period contributes to one-third of maternal deaths, highlighting the need for improved clinical knowledge and technology for long-term prevention, particularly in underserved areas [14, 15].

Evidence-based guidelines for postpartum care can mitigate mid- and long-term complications, inform clinical management, and contribute to policy-making and unified care across healthcare departments and professions [12, 16]. The adaptation of clinical guidelines is essential to ensure their relevance and feasibility in local contexts, requiring significant resources, expertise, and coordination involving multidisciplinary experts, continuous supervision, and evaluation [17, 18].

Authentic and comprehensive clinical guidelines, such as the WHO Recommendations on Postnatal Care of the Mother and Newborn and the NICE guideline for postnatal care, provide a basis for routine care for mothers and newborns, with the potential for standardizing postnatal services through adaptation and utilization of international clinical guidelines [16, 19].

Considering the absence of comprehensive and current postnatal guidelines in Iran, as well as the WHO’s suggestion for the adaptation and utilization of clinical guidelines, this study aims to provide evidence-based recommendations for enhancing postnatal care in Iran, taking into account the sociocultural and healthcare system context of the country [12, 20].

Methods

This study is the first phase of a multi-phase research that its protocol has already been published [21]. It is a multi-stage developmental research using systematic review and qualitative methods. It is aimed at the cultural adaptation of postnatal clinical guidelines in Tabriz University of Medical Sciences in 2023. The ADAPTE method has been used for the cultural adaptation of the clinical guidelines in the present study. Generally, ADAPTE includes three stages [18, 22]:

First phase: set-up

During the set-up phase, the adaptation team was formed. The cultural adaptation team consists of 6 people (two reproductive health specialists, a perinatologist, a PhD in evidence-based studies, a PhD student in midwifery, and a senior expert in Medical Library and Information Science). The topic selection criteria were set. Also, the feasibility of adaptation of the clinical guideline was evaluated based on the availability of authentic international postnatal clinical guidelines, and then, the adaptation plan was prepared.

Second phase: adaptation (search, and evaluation of the clinical guidelines)

Since the team aimed to adapt a clinical guideline for postnatal care, the search to find suitable clinical guidelines was conducted. A PIPOH-based search strategy was used to find the clinical guidelines and other relevant documents. The keyword “postpartum” was searched for in the Mesh and the terms “Postpartum Period” and “Postnatal Care” which were related to the searched keyword were retrieved. No Mesh equivalents were found for the keyword “Guideline”, so the search was conducted using the ‘Publication Type’ and ‘title/abstract’. The search for the relative keywords was conducted on the related websites (Table 1) in a 10-year period. In this phase, after removing duplicates, 17 guidelines and documents were selected. The selected guidelines are available as a supplementary file. Based on inclusion criteria (using the English language, availability of the full manuscript of the guideline, routine postpartum care, and being the latest or most common manuscript), and exclusion criteria (the target group not being the same and the topic background not matching), after the initial evaluations of the retrieved guidelines by the search team, 5 guidelines that were published within the last 5 years (Table 2) were primarily selected, which were evaluated and scrutinized for the second time. As the secondary selection, the guidelines were evaluated by two thematic experts, using the AGREE II Checklist. The AGREE II includes 23 appraisal criteria (items) organized within six domains. These domains are scope and purpose, stakeholder involvement, rigor of development, clarity of presentation, applicability, and editorial independence. Each criterion is given a score ranging from 1 (totally disagree) to 7 (totally agree). The score of each domain is calculated by the sum of the scores given to the criteria of that domain and standardizing the total score based on the maximum obtainable score for that domain. The quality score for all six domains was calculated [23, 24].

Table 1 The reliable sites to search for clinical guidelines

Table 2 Characteristics of the included guidelines

Regarding the high evaluation scores obtained by the WHO Recommendations on Postnatal Care of the Mother and Newborn (2022), and the National Institute for Health and Care Excellence (NICE) guideline for postnatal care (2021) (Table 3), these guidelines were selected for cultural adaptation. The recommendations for the preparation of the draft of the clinical guideline were selected and formulated in the form of a table.

Table 3 AGREE II domain scores for the included guidelines

Third phase: finalization (reviewing the target users and formulation of the final manuscript)

To reach a consensus on the clinical advantage and feasibility of cultural adaptation, the Delphi technique [25] was used to survey experts from different regions of the country via email. Eighteen experts from a variety of specialties, including reproductive health, obstetrics, midwifery, health policy, Evidence Based Medicine (EBM) and pediatrics, were invited to participate (Table 4). The panel of experts scored the recommendations in terms of the feasibility of cultural adaptation (low, medium, and high). The views and opinions of these experts were scored and summarized using a 9-item Likert scale. These points were scored from 1 to 9. Scores above 7 meant the approval of the recommendation, scores between 5 and 7 needed modifications in a second phase of Delphi, and scores lower than 4 meant the rejection of the recommendation. The most common definition of consensus, which is the agreement percentage, has been used for clinical advantage. An above-75% agreement was considered as the consensus threshold [26].

Table 4 Profile of cultural adaptation experts

The clinical guideline was sent to authorities (Ministry of Health and Medical Education) for consultation and their views were applied to it. Finally, the culturally adapted guideline was formulated after being summarized, judged, and agreed upon by the panel of experts. The evidence grades of the recommendations in this guideline were based on the sum of evidence strength according to the reference clinical guidelines and the opinions of the panel of experts (Table 5).

Table 5 Definition of level of evidence

Results

After the Delphi process, 56 clinical recommendations (Table 6) were developed in the form of care, prevention, treatment, education, and promotion of the health system themes. These recommendations were produced by a panel of experts from different regions of Iran and took into account the cultural, socio-economic, and health system constraints of the country. Out of those recommendations, 43 recommendations aligned with the WHO’s guidelines while 13 recommendations aligned with the NICE guidelines. As some recommendations in these guidelines overlapped, the WHO’s guideline were used as the main guideline, and the NICE guideline was used for some specific recommendations related to post-caesarean procedures. The recommendations are designed to improve maternal and child health outcomes and address the specific needs and contexts of these groups in Iran.

Table 6 Recommendations of adapted clinical guidelines for postpartum period

The recommendations are categorized into four major themes: (1) mother care (recommendations 1–17), (2) newborn care (recommendations 18–32), and (3) health system and health promotion interventions (recommendations 33–43). (4) post caesarean care (recommendations 46–56).

The mother care section, including different themes regarding maternal assessment, preventive interventions, mental health interventions, nutritional and physical activity interventions, and information and services for interval between pregnancies. Additionally, there were 10 recommendations specifically addressing the needs of women who had caesarean delivery, and 1 recommendation about the delivery experience and 2 recommendations about child safety and emotional connection with the child.

The neonatal section covers various areas such as physiological examination, preventive interventions, nutritional interventions, newborn growth and development, and breastfeeding.

The health system and health promotion section provides 11 recommendations addressing important areas such as health promotion, policy formulation, monitoring and evaluation, and evidence-based decision-making.

Discussion

The postpartum is a very sensitive period for the mothers and the newborn. The lack of comprehensive and up-to-date clinical guidelines in Iran has created a significant gap in the provision of postnatal care. Cultural adaptation of clinical guidelines for postpartum is a vital step to ensure that mothers, newborns, spouses, parents, and families receive suitable and evidence-based care in this critical period.

Among the evaluated guidelines, the WHO Recommendations on Postnatal Care of the Mother and Newborn (2022), and the National Institute for Health and Care Excellence (NICE, 2021) guideline for postnatal care obtained the highest scores in six appraisal domains with AGREE II. Also, in the study by Yang et al. [27], these guidelines obtained the highest score in terms of the use of the latest evidence, methodological quality, and the use of a multi-disciplinary team for the formulation of the recommemdations. The AGREE II is used to formulate or adapt the guideline. It was also used as a credible reference to evaluate the quality of clinical guidelines [28]. This tool has been used in various studies, as a standard benchmark for investigation of the quality of clinical guidelines [27, 29, 30].

The WHO Recommendations on Postnatal Care of the Mother and Newborn are about the common postnatal care for healthy mothers and newborns. This clinical guideline is a comprehensive collection of 55 recommendations that have provided the components of postnatal care in three main categories: a) maternal care (24 recommendations), b) newborn care (19 recommendations), and c) healthcare system and health promotion interventions (12 recommendations). Since the WHO’s guideline only covers vaginal birth and provides no recommendations for cesarean birth, and considering the high statistics of cesarean in our country [31, 32], the recommendation by the panel of experts who emphasized that the adapted guideline should be comprehensive and also cover the cesarean delivery, the National Institute for Health and Care Excellence (NICE) guideline for postnatal care was also used for post-cesarean care recommendations.

During the initial evaluation of the WHO’s guidelines by the cultural adaptation team, 5 maternal care recommendations were removed (No 3, 9, 15, 16, 17). Due to the low prevalence of tuberculosis, schistosomiasis, parasites (worms) and HIV in our country, recommendations related to tuberculosis screening, prevention of schistosomiasis, drug prevention of parasites (Preventive anthelminthic treatment), and Oral pre-exposure prophylaxis for HIV prevention were removed. Medical prevention of mastitis with subcutaneous oxytocin (No. 9) and vitamin A consumption in pregnancy (No. 21), which were not recommended by the WHO, were removed according to experts’ opinion.

The WHO’s recommendations on immediate postnatal evaluation of mother (No. 1) and HIV screening (No. 2) were formulated by some modifications after the first stage of Delphi and with the consensus of the experts. According to the WHO’s guidelines (No. 7), it is not recommended to do exercise to strengthen the pelvic floor muscles, but with the consensus of the experts (over 75% agreement), this recommendation was added to the adapted guideline.

Regarding the population policies of the country, and based on the opinions of the experts, the WHO’s recommendation on the provision of contraception information and services (No. 24) was changed into ‘provide information and services related to the interval between pregnancies. According to experts’ opinion, mothers should be advised to start vitamin A + D drops for infants from the 3rd to the 5th day after birth (No. 28).

In terms of post-cesarean pain relief in the NICE guideline, the ‘protocols of the related hospital for pain relief’ and names of some common pain relievers were added based on the experts’ recommendations (No. 47 b). In the recommendation of the NICE clinical guide regarding vaginal childbirth after cesarean section, according to experts, labor induction was omitted, because it is not performed in our country in mothers with a history of cesarean section.

The WHO recommendations related to health system and health promotion interventions, specifically recommendations 35, 36, 37, 38, 39, 41, 42 and 43, would require specific infrastructure to be effectively implemented in Iran. These recommendations include the criteria to be assessed prior to discharge after birth, midwifery continuity of care, home-based records, digital targeted client communication, and cultural considerations related to men’s involvement in some regions of the country. Although these recommendations may pose challenges to implement in the current state of the health system, experts agree that they should not be removed from the guideline, but rather should serve as a long-term goal to move the health system towards creating the necessary infrastructure to implement these recommendations effectively in the future.

Conclusion

By implementing evidence-based recommendations for the care of mothers and babies in the postpartum period, the healthcare system will be strengthened in order to promote the provision of care after vaginal and caesarean births. Additionally, a positive postnatal experience will be ensured for mothers, fathers, babies, and families. By adopting these recommendations, the overall health outcomes of mothers and babies during this critical period can be improved. The experts emphasize the importance of integrating these recommendations into healthcare policies and practices in order to promote a comprehensive and evidence-based approach to maternal and child health in Iran.