High fatality rate maternal with COVID-19: lesson learned tertiary hospital in Indonesia

Objective To compare and contrast methodology used for the Royal College of Obstetricians and Gynaecologist's (RCOG) COVID-19 guidance with established standards, as well as the RCOG's Green-top Guidelines. Case report The RCOG has developed guidance for over 20 years and currently publishes different formats including Green-top Guidelines (GTG), which achieved NICE accreditation renewal in 2020. In March 2020, the RCOG started developing guidance to support women and healthcare professionals working in maternity and/or gynaecology services during the COVID- 19 pandemic. In this case study we describe the development of the RCOG/RCM Coronavirus Infection and Pregnancy guidance (https://www.rcog.org.uk/en/guidelines-research-se rvices/guidelines/coronavirus-pregnancy/). We compare and contrast the methods used, both with internationally agreed principles for developing guidance during the COVID-19 pandemic and those used by Green-top Guidelines, in order to understand what can be learned for future guideline development. To meet the need for timely guidance, Green-top Guideline methodology was not suitable for the COVID-19 Infection and Pregnancy guidance co-developed by the RCOG and RCM. Instead, the development team initially published emergency guidance using pragmatic methods. They later adopted methods to align with principles on guidelines development processes during the pandemic, as outlined by the Guidelines International Network, adapting these where appropriate. These principles include: Convening a multi-disciplinary group;Defining the scope of the guidance;Describing the methods used, including how the evidence was identified and reviewed, how the recommendations were agreed and how they link to the evidence. Undertaking external review;and Specifying when the guidance will be reviewed and updated. Discussion Through establishing and refining methods in accordance with the principles of the Guidelines International Network, whilst striving to review evidence and implement policy changes on a weekly basis, important differences between the methods and purpose of the COVID- 19 Infection and Pregnancy guidance and the Green-top Guidelines emerge. The most significant of these differences relate to the emergent and low quality nature of the evidence base, the uncertain trajectory of the pandemic, the lack of a formal critical appraisal tool used and the associated grading of evidence and recommendations. Conclusion The pandemic created an unprecedented need to rapidly develop guidance for maternity healthcare professionals in the UK and around the world, as well as information for women themselves. Those developing this guidance are required to continuously balance the need for up-to-date guidance with the time and resource required to follow a high quality development process.