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

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. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-024-11026-8.


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 longterm 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 multistage 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].
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.

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].
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).

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.
The recommendations are categorized into four major themes: (1)  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 upto-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

A
Criteria to be assessed prior to discharge from the health facility after birth 35."Prior to discharging women and newborns after birth from the health facility to the home, health workers should assess the following criteria to improve maternal and newborn outcomes: • The woman's and baby's physical well-being and the woman's emotional well-being; • The skills and confidence of the woman to care for herself and the skills and confidence of the parents and caregivers to care for the newborn; and • The home environment and other factors that may influence the ability to provide care for the woman and the newborn in the home, and care-seeking behavior" B

B
Involvement of men in postnatal care and maternal and newborn health 41. "Interventions to promote the involvement of men during pregnancy, childbirth and after birth are recommended to facilitate and support improved self-care of women, home care practices for women and newborns, and use of skilled care for women and newborns during pregnancy, childbirth and the postnatal period, and to increase the timely use of facility care for obstetric and newborn complications These interventions are recommended, provided they are implemented in a way that respects, promotes and facilitates women's choices and their autonomy in decisionmaking, and that supports women in taking care of themselves and their newborns"   [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 longterm 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.

4 .AAA
"Oral paracetamol (acetaminophen) 325 mg every 6 h is recommended as first-line choice when oral analgesia is required for the relief of postpartum perineal pain" A Pharmacological relief of pain due to uterine cramping/involution 5. "Oral non-steroidal anti-inflammatory drugs (NSAIDs) can be used when analgesia is required for the relief of postpartum pain due to uterine cramping after childbirth, based on a woman's preferences, the clinician's experience with analgesics and availability"Postnatalpelvic floor muscle training for pelvic floor strengthening 6. "For postpartum women, starting routine pelvic floor muscle training (PFMT) after childbirth for the prevention of postpartum urinary and faucal incontinence is recommended" B Non-pharmacological interventions to treat postpartum breast engorgement 7. "For treatment of breast engorgement in the postpartum period, women should be counselled and supported to practice responsive breastfeeding, good positioning and attachment of the baby to the breast, expression of breastmilk, and the use of warm or cold compresses, based on a woman's preferences" A Preventive measures Non-pharmacological interventions to prevent postpartum mastitis 8. "For the prevention of mastitis in the postpartum period, women should be counselled and supported to practice responsive breastfeeding, good positioning and attachment of the baby to the breast, hand expression of breastmilk, and the use of warm or cold compresses, based on a woman's preferences" A Pharmacological interventions to prevent postpartum mastitis 9. "Routine oral or topical antibiotic prophylaxis for the prevention of mastitis in the postpartum period is not recommended" 10 a. "Dietary advice and information on factors associated with constipation should be offered to women for the prevention of postpartum constipation" A 10 b. "Routine use of laxatives for the prevention of postpartum constipation is not recommended" Prevention of maternal peripartum infection after uncomplicated vaginal birth 11. "Routine antibiotic prophylaxis for women with uncomplicated vaginal birth is not recommended" A Mental health interventions Screening for postpartum depression and anxiety 12. "Screening for postpartum depression and anxiety using a validated instrument is recommended and should be accompanied by diagnostic and management services for women who screen positive" A Prevention of postpartum depression and anxiety 13. "Psychosocial and/or psychological interventions during the antenatal and postnatal period are recommended to prevent postpartum depression and anxiety" A Nutritional interventions and physical activity Postpartum oral iron and folate supplementation 14. "Oral iron supplementation, either alone or in combination with folic acid supplementation, may be provided to postpartum women for 6-12 weeks following childbirth for reducing the risk of anemia in settings where gestational anemia is of public health concern" Postpartum vitamin A supplementation 15. "Vitamin A supplementation in postpartum women for the prevention of maternal and infant morbidity and mortality is not recommended" A Physical activity and sedentary behaviour 16 a."All postpartum women without contraindication should: • Undertake regular physical activity throughout the postpartum period;

B
Home-based records 42."The use of home-based records, as a complement to facility-based records, is recommended for the care of pregnant and postpartum women, newborns and children, to improve care-seeking behaviour, men's involvement and support in the household, maternal and child home care practices, infant and child feeding, and communication between health workers and women, parents and caregivers" C Digital targeted client communication 43."WHO recommends digital targeted client communication for behaviour change regarding sexual, reproductive, maternal, newborn and child health, under the condition that concerns about sensitive content and data privacy are adequately addressed" B NICE Recommendations Principles of care 44."When caring for a woman who has recently given birth, listen to her and be responsive to her needs and preferences" "Discuss with parents' safer practices for bed sharing, including: • Making sure the baby sleeps on a firm, flat mattress, lying face up (rather than face down or on their side) • Not sleeping on a sofa or chair with the baby • Not having pillows or duvets near the baby • Not having other children or pets in the bed when sharing a bed with a baby" A 45 b. "Strongly advise parents not to share a bed with their baby if their baby was low birth weight or if either parent: • Has had 2 or more units of alcohol • Smokes • Has taken medicine that causes drowsiness • Has used recreational drugs" A Promoting emotional attachment 46 a. "Before and after the birth, discuss the importance of bonding and emotional attachment with parents, and the approaches that can help them to bond with their baby" A 46 b. "Encourage parents to value the time they spend with their baby as a way of promoting emotional attachment, including: • Face-to-face interaction • Skin-to-skin contact • Responding appropriately to the baby's cues" A 46 c. "Discuss with parents the potentially challenging aspects of the postnatal period that may affect bonding and emotional attachment, including: • the woman's physical and emotional recovery from birth • Experience of a traumatic birth or birth complications • Fatigue and sleep deprivation • Feeding concerns • Demands of parenthood" B 46 d. "Recognise that additional support in bonding and emotional attachment may be needed by some parents who, for example: • Have been through the care system • Have experienced adverse childhood events • Have experienced a traumatic birth • Have complex psychosocial needs" B

Table 1
The reliable sites to search for clinical guidelines

Table 2
Characteristics of the included guidelines

Table 4
Profile of cultural adaptation experts

Table 5
Definition of level of evidence

Table 6
Recommendations of adapted clinical guidelines for postpartum period All postpartum women should have regular assessment of vaginal bleeding, uterine tonus, fundal height, temperature and heart rate (pulse) routinely during the first 24 h, starting from the first hour after birth.In the first hour after delivery", blood pressure should be measured every 15 min to one hour, then every half hour to two hours according to the country's protocol.Urine void should be documented within 6 hAt each subsequent postnatal contact beyond 24 h after birth, enquiries should continue to be "made about general well-being and assessments made regarding the following: micturition and urinary incontinence, bowel function, healing of any perineal wound, headache, fatigue, back pain, perineal pain and perineal hygiene, breast pain and uterine tenderness and lochia." AHIV catch-up testing 2. For women who are HIV negative or have an unknown HIV status, who are considered to be at high risk of contracting HIV (such as people whose sexual partners are infected, or who themselves or their spouses are addicted to injecting drugs), If they have not done the test at the first pregnancy visit or the re-test at the end of pregnancy in the third trimester, it is necessary to do an HIV test AInterventions for

common physiological signs and symptoms Local cooling for perineal pain relief
3. "Local cooling, such as with ice packs or cold pads, can be offered to women in the immediate postpartum period for the relief of acute pain from perineal trauma sustained during childbirth, based on a woman's preferences and available options" A Oral analgesia for perineal pain relief

Table 6 (
The following signs should be assessed during each postnatal care contact, and the newborn should be referred for further evaluation if any of the signs is present: not feeding well; history of convulsions; fast breathing (breathing rate > 60 per minute); severe chest in-drawing; no spontaneous movement; fever (temperature > 37.5 °C); low body temperature (temperature < 35.5 °C); any jaundice in first 24 h after birth, or yellow palms and soles at any age" "The parents and family should be encouraged to seek health care early if they identify any of the above danger signs between postnatal care visits"A continued)

Health systems and health promotion interventions Schedules for postnatal care contacts
33. "A minimum of four postnatal care contacts is recommended.If birth is in a health facility, healthy women and newborns should receive postnatal care in the facility for at least 24 h after birth.If birth is at home, the first postnatal contact should be as early as possible within 24 h of birth.At least three additional postnatal contacts are recommended for healthy women and newborns, between48 and 72 h, between 7 and 14 days, and during week six after birth" ALength of stay in health facilities after birth 34."Care for healthy women and newborns in the health facility is recommended for at least 24 h after vaginal birth"

Table 6 (continued) Care category Recommendation Level of evidence Approaches to strengthen preparation for discharge from the health facility to home after birth 36
. "Information provision, educational interventions and counselling are recommended to prepare women, parents and caregivers for discharge from the health facility after birth to improve maternal and newborn health outcomes, and to facilitate the transition to the home.Educational materials, such as written/digital education booklets, pictorials for semi-literate populations and job aids should be available"

of staff in rural and remote areas 40
. "Policy-makers should consider a bundle of interventions covering education, regulation, incentives and personal and professional support to improve health workforce development, attraction, recruitment and retention in rural and remote areas"

Table 6 (
continued) Inform women who have had up to and including repeat caesarean births that the risk of fever, bladder injuries and surgical injuries does not vary with planned mode of birth, but that the risk of uterine rupture is higher for planned vaginal birth" Pregnant women with both previous caesarean birth and a previous vaginal birth should be informed that they have an increased likelihood of having a vaginal birth than women who have had a previous caesarean birth but no previous vaginal birth" A 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 byYang et al.