The system of healthcare in Russia requires physicians to follow directives and methodological recommendations from
oblast health authorities and the Ministry of Health. Since the new clinical content would require clinical practices outside of
existing directives and methodological recommendations, facility teams could not make these decisions alone: they
made decisions in close collaboration with Russian experts in maternal health and incorporated involvement from the
Ministry of Health. This required policy dialog, reviews of clinical evidence, and debate before an agreement could be
reached. The Head of Maternal Health in the MOH RF was especially helpful in approving the guideline and clinical
changes at the federal level.