6.1. Anticipated impact on the organization of care and resources

Implementing this evidence-based recommendation requires health workers to identify and provide counselling to those women with pregnancies that have reached or gone beyond term. Health worker shortages may also reduce the feasibility of performing ANC ultrasound scans and other risk assessments (16, 31). The GDG noted that updating training curricula and providing training on accurate gestational age assessment would increase the impact and facilitate implementation of the recommendation.

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 professionals, and to the organization of care or health-service delivery.

As part of efforts to implement this recommendation, health system stakeholders should consider the need to ensure (33, 34):

• one scan before 24 weeks of gestation for accurate estimation of gestational age;
• post-term pregnancy risk assessment; and
• schedule planning that allows for adequate time to provide information and counselling in ANC clinics.

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 (35) 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 be considered.

• The proportion of pregnant women who have an ultrasound prior to 24 weeks of gestation.
• The proportion of pregnant women who have a documented indication for undergoing induction of labour.