6Applicability issues

6.1. Anticipated impact on the organization of care and resources

A number of factors may hinder the effective implementation and scale-up of this recommendation. These factors may be related to the behaviours of patients (women or families) or health-care professionals and to the organization of care or health service delivery. As part of efforts to implement this recommendation, health system stakeholders may wish to consider the following potential barriers to their application:

• lack of understanding of the value of routine antibiotic prophylaxis for women undergoing operative vaginal birth among women giving birth, families or communities;
• lack of human resources with the necessary training and skills to deliver routine antibiotic prophylaxis for operative vaginal birth;
• concerns from skilled care personnel and system managers regarding the safety of routine antibiotic prophylaxis for operative vaginal birth, including antimicrobial resistance;
• lack of reliable supply systems and sustained availability and equitable access to antibiotics for use in obstetrics listed in the WHO model list of essential medicines;
• lack of current systems in place to monitor the use of antibiotics and antimicrobial resistance;
• lack of effective referral mechanisms and care pathways for women identified as needing additional care.

6.2. Monitoring and evaluating guideline implementation

The implementation and impact of this recommendation will be monitored at the health service, country and regional levels, as part of broader efforts to monitor and improve the quality of maternal and newborn care. The WHO document Standards for improving quality of maternal and newborn care in health facilities (36) provides a list of prioritized input, output and outcome measures that can be used to define quality of care criteria and indicators and that should be aligned with locally agreed targets. In collaboration with the monitoring and evaluation teams of the WHO Department of Sexual and Reproductive Health and Research and the WHO Department of Maternal, Newborn, Child and Adolescent Health and Ageing, data on country- and regional-level implementation of the recommendation can be collected and evaluated in the short to medium term to assess its impact on national policies of individual WHO Member States.

Information on recommended indicators can also be obtained at the local level by interrupted time series or clinical audits. In this context, the GDG suggests the following indicators to be considered:

• Proportion of women undergoing operative vaginal birth who receive antibiotic prophylaxis, calculated as the number of women who receive antibiotic prophylaxis for operative vaginal birth divided by the total number of women undergoing operative vaginal birth.
• Incidence of peripartum infection among women undergoing operative vaginal birth, calculated as the number of women with peripartum infection after operative vaginal birth divided by the total number of women undergoing operative vaginal birth.

The first indicator provides an assessment of the use of evidence-based practices among women considered at higher risk of infection around childbirth, while the second indicator provides information on the efficacy of the intervention. WHO has developed specific guidance for evaluating the quality of care for severe maternal complications (including sepsis) based on the near-miss and criterion-based clinical audit concepts (37).