Development of clinical guidelines in a health district: an attempt to find consensus.

OBJECTIVE To formulate consensus based guidelines for antenatal care in a health district. DESIGN Prospective formulation of draft guidelines by a working group of consultant obstetricians and general practitioners with an obstetric interest, canvassing opinions of all GPs in the district by questionnaire, and revision and final circulation of the guidelines. SETTING One health district. SUBJECTS All 160 GPs in the district and members of the working party. MAIN MEASURES Questionnaire responses to specific proposals within the draft guidelines for managing anaemia, antepartum haemorrhage, and hypertension. RESULTS 136 GPs responded (response rate 85%); responders and nonresponders did not differ in age, sex, or presence on obstetric list. Overall they favoured more conservative management than suggested in the guidelines. For example, only 38% (44/116) prescribed iron routinely and 34% (38/113) referred to hospital for haemoglobin concentration of < or = 10 g/l; 10% referred women unnecessarily for oedema unassociated with proteinuria; and 20% managed active bleeding progressing to old brown staining as an urgent admission. The guidelines were revised according to the relative weight of the views obtained. CONCLUSION Establishing guidelines is mainly a political process. Canvassed views influenced guidelines most when internal disagreement existed within the working party. IMPLICATIONS AND ACTION Regular revising of the guidelines is planned, which, in conjunction with repeating the questionnaire to monitor changing practice, will allow a long term district wide clinical review.