Adapting maternal health practice to co-morbidities and social inequality: A systematic approach.

The process of adapting universal guidelines to local institutional and cultural settings is recognized as important to their implementation and uptake. However, clarity on what, why and how to adapt in an evidence-based manner is still somewhat elusive. Health providers in low and middle income country contexts often have to deal with widely present co-morbidities and social inequalities among pregnant women. Since neither of these problems finds adequate discussion within the usual guidelines, and given the continual pressures posed by resource scarcity, health providers respond through ad hoc adaptations inimical to maternal safety and equity. We argue for, and describe, a grounded process of systematic adaptation of available guidelines through the example of a handbook on maternal risks for primary care doctors and staff nurses. The systematic adaptation in this practical, action-oriented handbook builds on research for a long-standing community-based project on maternal safety and rights. It takes a case-based problem-solving approach. Reiterating guidelines and best practices in diagnostic decision-making and risk management, it indicates how these can respond to co-morbidities and social inequality via complex clinical cases and new social science information.