Effectiveness of utilizing the WHO safe childbirth checklist on improving essential childbirth practices and maternal and perinatal outcome: A systematic review and meta-analysis

Impact of the WHO safe childbirth checklist on birth attendant behavior and maternal-newborn outcomes: A systematic review and meta-analysis

BACKGROUND

The intrapartum period is critical for reducing maternal and perinatal morbidity and mortality. The WHO's Safe Childbirth Checklist (SCC) was designed as a reminder of the most critical, evidence-based practices (EBPs) to improve quality care and reduce preventable complications and deaths.

OBJECTIVE

To assess the impact of SCC on birth attendant behavior and maternal and newborn health outcomes.

SEARCH STRATEGY

A systematic review and meta-analysis was performed searching across five databases from 2009 to 2023.

SELECTION CRITERIA

We included randomized controlled trials, quasi-experimental studies, and pre/post studies.

DATA ANALYSIS

A meta-analysis yielded a pooled estimate of relative risk (RR) for adherence to and effectiveness of the SCC.

MAIN RESULTS

Of 1070 articles identified, 16 were included. Use of the SCC increased adherence to EBPs by 65% (RR 1.65; 95% confidence interval [CI] 1.34-2.02). The behaviors that improved the most were danger sign counseling (RR 12.37; 95% CI 1.95-78.52; P = 0.008) and pre-eclampsia management (RR 3.43; 95% CI 1.33-8.88; P = 0.011). There was moderate evidence for stillbirth reduction (RR 0.89; 95% CI 0.80-0.99; P = 0.034).

CONCLUSION

There is moderate evidence demonstrating the effectiveness of the SCC in reducing stillbirths and improving adherence to EBPs.

Near-Term and Intrapartum Care of Mothers for Perinatal and Newborn Outcomes

INTRODUCTION

Near-term and intrapartum care play pivotal roles in ensuring a safe childbirth experience and are essential components of a comprehensive approach to maternal and neonatal health.

METHODS

The following interventions were identified: antibiotics for preterm premature rupture of membrane, antenatal corticosteroids for fetal lung maturation, partograph use during labor and delivery, induction of labor at or post-term, skilled birth care and safe childbirth checklist during labor and delivery. A scoping exercise was conducted to ascertain the most up-to-date evidence, and reviews of topics of interest were updated in case the evidence was not recent, with a focus on low- and middle-income countries (LMICs).

RESULTS

Antibiotics reduced the overall risk of neonatal infection including pneumonia (RR 0.67 [0.52 to 0.85]). LMIC evidence showed a significant effect of antenatal steroids on the risk of neonatal mortality (RR 0.64 [0.43 to 0.97]) and respiratory distress syndrome (RR 0.65 [0.44 to 0.96]). Induction of labor practices at term or post-term reduced the risk of meconium aspiration syndrome (RR 0.51 [0.34 to 0.76]). The use of the WHO childbirth checklist significantly raised the standard of preeclampsia care (OR 8.09 [2.55 to 25.63]) as well as of maternal infection management (OR 25.44 [4.09 to 158.08]). LMIC-specific evidence also demonstrated a significant reduction in the risk of stillbirth (OR 0.92 [0.87 to 0.96]).

CONCLUSION

Further research initiatives pertaining to health interventions delivered to expectant mothers near-term or during the intrapartum period can contribute to a more inclusive understanding of health challenges in LMICs.

INTRODUCTION

Near-term and intrapartum care play pivotal roles in ensuring a safe childbirth experience and are essential components of a comprehensive approach to maternal and neonatal health.

METHODS

The following interventions were identified: antibiotics for preterm premature rupture of membrane, antenatal corticosteroids for fetal lung maturation, partograph use during labor and delivery, induction of labor at or post-term, skilled birth care and safe childbirth checklist during labor and delivery. A scoping exercise was conducted to ascertain the most up-to-date evidence, and reviews of topics of interest were updated in case the evidence was not recent, with a focus on low- and middle-income countries (LMICs).

RESULTS

Antibiotics reduced the overall risk of neonatal infection including pneumonia (RR 0.67 [0.52 to 0.85]). LMIC evidence showed a significant effect of antenatal steroids on the risk of neonatal mortality (RR 0.64 [0.43 to 0.97]) and respiratory distress syndrome (RR 0.65 [0.44 to 0.96]). Induction of labor practices at term or post-term reduced the risk of meconium aspiration syndrome (RR 0.51 [0.34 to 0.76]). The use of the WHO childbirth checklist significantly raised the standard of preeclampsia care (OR 8.09 [2.55 to 25.63]) as well as of maternal infection management (OR 25.44 [4.09 to 158.08]). LMIC-specific evidence also demonstrated a significant reduction in the risk of stillbirth (OR 0.92 [0.87 to 0.96]).

CONCLUSION

Further research initiatives pertaining to health interventions delivered to expectant mothers near-term or during the intrapartum period can contribute to a more inclusive understanding of health challenges in LMICs.

Is pregnancy a disease? A normative approach

In this paper, we identify some key features of what makes something a disease, and consider whether these apply to pregnancy. We argue that there are some compelling grounds for regarding pregnancy as a disease. Like a disease, pregnancy affects the health of the pregnant person, causing a range of symptoms from discomfort to death. Like a disease, pregnancy can be treated medically. Like a disease, pregnancy is caused by a pathogen, an external organism invading the host's body. Like a disease, the risk of getting pregnant can be reduced by using prophylactic measures. We address the question of whether the 'normality' of pregnancy, its current necessity for human survival, or the value often attached to it are reasons to reject the view that pregnancy is a disease. We point out that applying theories of disease to the case of pregnancy, can in many cases illuminate inconsistencies and problems within these theories. Finally, we show that it is difficult to find one theory of disease that captures all paradigm cases of diseases, while convincingly excluding pregnancy. We conclude that there are both normative and pragmatic reasons to consider pregnancy a disease.

Neonatal bacterial sepsis

Neonatal sepsis remains one of the key challenges of neonatal medicine, and together with preterm birth, causes almost 50% of all deaths globally for children younger than 5 years. Compared with advances achieved for other serious neonatal and early childhood conditions globally, progress in reducing neonatal sepsis has been much slower, especially in low-resource settings that have the highest burden of neonatal sepsis morbidity and mortality. By contrast to sepsis in older patients, there is no universally accepted neonatal sepsis definition. This poses substantial challenges in clinical practice, research, and health-care management, and has direct practical implications, such as diagnostic inconsistency, heterogeneous data collection and surveillance, and inappropriate treatment, health-resource allocation, and education. As the clinical manifestation of neonatal sepsis is frequently non-specific and the current diagnostic standard blood culture has performance limitations, new improved diagnostic techniques are required to guide appropriate and warranted antimicrobial treatment. Although antimicrobial therapy and supportive care continue as principal components of neonatal sepsis therapy, refining basic neonatal care to prevent sepsis through education and quality improvement initiatives remains paramount.

Implementation of the WHO Safe Childbirth Checklist: a scoping review protocol

INTRODUCTION

The WHO Safe Childbirth Checklist (WHO SCC) was developed to accelerate adoption of essential practices that prevent maternal and neonatal morbidity and mortality during childbirth. This study aims to summarise the current landscape of organisations and facilities that have implemented the WHO SCC and compare the published strategies used to implement the WHO SCC implementation in both successful and unsuccessful efforts.

METHODS AND ANALYSIS

This scoping review protocol follows the guidelines of the Joanna Briggs Institute. Data will be collected and reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews report. The search strategy will include publications from the databases Scopus, PubMed, Embase, CINAHL and Web of Science, in addition to a search in grey literature in The National Library of Australia's Trobe, DART-Europe E-Theses Portal, Electronic Theses Online Service, Theses Canada, Google Scholar and Theses and dissertations from Latin America. Data extraction will include data on general information, study characteristics, organisations involved, sociodemographic context, implementation strategies, indicators of implementation process, frameworks used to design or evaluate the strategy, implementation outcomes and final considerations. Critical analysis of implementation strategies and outcomes will be performed with researchers with experience implementing the WHO SCC.

ETHICS AND DISSEMINATION

The study does not require an ethical review due to its design as a scoping review of the literature. The results will be submitted for publication to a scientific journal and all relevant data from this study will be made available in Dataverse.

TRIAL REGISTRATION NUMBER

https://doi.org/10.17605/OSF.IO/RWY27.

Implementing a clinical checklist for pregnant patients with opioid use disorder

BACKGROUND

Opioid use disorder (OUD) has been increasing in pregnant patients over the past two decades. Best practice guidelines that are available for these patients, must now be implemented by health care teams. Clinical checklists have been used for other complex patient cohorts with good success and are a potentially viable tool for ensuring best practices with this patient population as well.

LOCAL PROBLEM

Maine has seen a dramatic increase in the number of pregnant patients with OUD. Many of these patients seemed to "fall through the cracks" in the traditional prenatal care model. The obstetrical care team expressed feeling overwhelmed by the complex care needs of these patients and unsure of how to improve their care.

METHODS

To improve prenatal care delivery for patients with OUD, we implemented an evidence-based clinical checklist. This local, NP-led quality improvement project was done in partnership with a state-led initiative to improve perinatal care for patients with OUD.

INTERVENTIONS

An evidence-based checklist provided by the state initiative was implemented for prenatal patients with diagnosed OUD.

RESULTS

Use of a clinical checklist for patients with OUD increased the rate of several best practices during their prenatal care, including emergency naloxone prescription, tracking prescription monitoring reports, and contraceptive planning. Rates of completed prenatal screening for substance misuse, social determinants of health, and intimate partner violence also increased in our practice overall, as a result of this project.

CONCLUSIONS

To further improve perinatal care coordination for patients with OUD, we recommend future evaluation of clinical checklists within various practice settings.

Impact of the WHO Safe Childbirth Checklist on safety culture among health workers: A randomized controlled trial in Aceh, Indonesia

The World Health Organization (WHO) developed the Safe Childbirth Checklist (SCC) to increase the application of essential birth practices to ultimately reduce perinatal and maternal deaths. We study the effects of the SCC on health workers safety culture, in the framework of a cluster-randomized controlled trial (16 treatment facilities/16 control facilities). We introduced the SCC in combination with a medium intensity coaching in health facilities which already offered at minimum basic emergency obstetric and newborn care (BEMonC). We assess the effects of using the SCC on 14 outcome variables measuring self-perceived information access, information transmission, frequency of errors, workload and access to resources at the facility level. We apply Ordinary Least Square regressions to identify an Intention to Treat Effect (ITT) and Instrumental Variable regressions to determine a Complier Average Causal Effect (CACE). The results suggest that the treatment significantly improved self-assessed attitudes regarding the probability of calling attention to problems with patient care (ITT 0.6945 standard deviations) and the frequency of errors in times of excessive workload (ITT -0.6318 standard deviations). Moreover, self-assessed resource access increased (ITT 0.6150 standard deviations). The other eleven outcomes were unaffected. The findings suggest that checklists can contribute to an improvement in some dimensions of safety culture among health workers. However, the complier analysis also highlights that achieving adherence remains a key challenge to make checklists effective.

Evaluation of Dakshata, a scale-up WHO SCC and mentoring-based program, for improving quality of intrapartum care in public sector in Rajasthan, India: repeated mixed-methods surveys

BACKGROUND

The Dakshata program in India aims to improve resources, providers' competence, and accountability in labour wards of public sector secondary care hospitals. Dakshata is based on the WHO Safe Childbirth Checklist coupled with continuous mentoring. In Rajasthan state, an external technical partner trained, mentored and periodically assessed performance; identified local problems, supported solutions and assisted the state in monitoring implementation. We evaluated effectiveness and factors contributing to success and sustainability.

METHODS

Using three repeated mixed-methods surveys over an 18-month period, we assessed 24 hospitals that were at different stages of program implementation at evaluation initiation: Group 1, training had started and Group 2, one round of mentoring was complete. Data on recommended evidence-based practices in labour and postnatal wards and in-facility outcomes were collected by directly observing obstetric assessments and childbirth, extracting information from case sheets and registers, and interviewing postnatal women. A theory-driven qualitative assessment covered key domains of efficiency, effectiveness, institutionalization, accountability, sustainability, and scalability. It included in-depth interviews with administrators, mentors, obstetric staff, and officers/mentors from the external partner.

RESULTS

Overall, average adherence to evidence-based practices improved: Group 1, 55 to 72%; and Group 2, 69 to 79%, (for both p < 0.001) from baseline to endline. Significant improvement was noted in several practices in the two groups during admission, childbirth, and within 1 hour of birth but less in postpartum pre-discharge care. We noted a dip in several evidence-based practices in 2nd assessment, but they improved later. The stillbirth rate was reduced: Group 1: 1.5/1000 to 0.2; and Group 2: 2.5 to 1.1 (p < 0.001). In-depth interviews revealed that mentoring with periodic assessments was highly acceptable, efficient means of capacity building, and ensured continuity in skills upgradation. Nurses felt empowered, however, the involvement of doctors was low. The state health administration was highly committed and involved in program management; hospital administration supported the program. The competence, consistency, and support from the technical partner were highly appreciated by the service providers.

CONCLUSION

The Dakshata program was successful in improving resources and competencies around childbirth. The states with low capacities will require intensive external support for a head start.

The status quo and influencing factors of knowledge, attitude and practice of obstetric staff on the safe childbirth checklist

Practical Guidelines for Safe Childbirth Checklist has not been widely used in medical institutions at all levels in China. This study aims to understand the current status of knowledge, attitude and practice of obstetric medical staff toward the Safe Childbirth Checklist and analyze its influencing factors to provide a reference for establishing the promotion of the checklist. Convenience sampling was used in a cross-sectional survey of 685 obstetric medical staff in Chongqing using a self-designed questionnaire to analyze their knowledge, attitude and practice of the checklist. The scores of knowledge, attitude and practice of obstetric medical staff on the checklist were 29.96 ± 5.44, 62.87 ± 9.11, and 37.74 ± 6.82, respectively. Occupation and hospital level were influencing factors of the knowledge and practice scores, while length of service was the only influencing factor of the knowledge score. Education was the influencing factor of attitude score. The total effects of the knowledge, facilitation and inhibition dimensions on practice were 0.671, 0.263 and -0.135, respectively. Mediating effects presented in the facilitation and inhibition of attitude in safe childbirth. Obstetrics medical staff know the checklist well, however, their attitudes and practices need to be improved. Managers should take targeted measures to strengthen the attitudes and practices of obstetric medical staff toward safe childbirth and promote the use of the checklist, thus providing a powerful safeguard for higher delivery quality and safer delivery.

Examining the variations in the implementation of interventions to address stillbirth from the national to subnational levels: experiences from Uganda

Background

The current global burden of stillbirth disproportionately affects regions such as sub-Saharan Africa, where Uganda is located. To respond to this burden, policies made at the national level were diffused from the centre and translated into service delivery at the district level, which is charged with implementation under the decentralization of health services arrangement. Variations emerge whenever policy recommendations are moved from national to subnational levels, with some aspects often lost along the way. Tools are available to facilitate knowledge of determinants of policy and innovation implementation within the healthcare system. However, the extent to which these have been applied to explain variations in implementation of interventions to address stillbirth reduction in Uganda remains scant. The aim of this article was to examine the variations in the implementation of interventions to address stillbirth from the national to the subnational levels in Uganda using the Consolidated Framework for Implementation Research (CFIR).

Methods

The study adopted a qualitative case study design. Data were collected from a purposively selected sample of key informants drawn from both the national and subnational levels. All interviews were conducted in English and transcribed verbatim. ATLAS.ti was used to guide the coding process, which used a codebook developed following the CFIR domains as codes and constructs as sub-codes. Analysis followed a content analysis technique.

Results

National-level factors that favoured implementation of interventions to address stillbirth included the desire to comply with global norms, incentives to improve performance for stillbirth reduction indicators for better comparison with global peers, and clear policy alternatives as process implementation advanced by champions. Variations at the subnational level revealed aspirations to address service delivery gaps which fell within maternal health routine standard of care and ongoing health systems strengthening initiatives. Coalescing existing networks around maternal and child health was a key mobilization factor for advocacy and programming, with a promise that the set targets would be operationalized at the subnational level. The key champions were defined by their official roles within the district health systems, which enhanced accountability. Feedback and reflection were distinguished from the national to subnational through joint assemblies and formal audit reviews, respectively.

Conclusions

A heavy influence of the global events directed national-level adaptation of interventions to address stillbirth. Implementation context at the subnational level led to local adaptation and translation of policy provisions from the national level to suit the context, which to a greater extent explains the variations in the final content of policy provisions delivered.

Effect of WHO-SCC based intra-department mentoring program on quality of intrapartum care in public sector secondary hospitals in Andhra Pradesh, India: Pre-post mixed methods evaluation

Quality of intrapartum care is essential for improving pregnancy outcomes; several models for improving performance are tested, globally. Dakshata is one such WHO SCC-based national program-improving resources, providers' competence, and accountability-in public sector secondary care hospitals of India. Andhra Pradesh state devised strategy of mentoring by the handpicked member from within the obstetric team, supported by external technical partner. We evaluated the effectiveness and assessed contextual factors to success of the program. We conducted pre and post mentoring mixed-method surveys to evaluate the change in evidence-based intrapartum and newborn care practices and stillbirth rates, across 23 of 38 eligible hospitals. We directly observed obstetric assessments and childbirth, extracted data from casesheets and registers, interviewed beneficiaries and conducted facility surveys. We in-depth interviewed stakeholders from state, district and facility managers, mentors and obstetric staff, and external managers for theory-driven qualitative assessment. After one year we found, average adherence to practices sustained high during admission (81%, 81%); improved during childbirth (78%, 86%; p = 0.016); moderate within one hour of birth (72%, 71%), and poor postpartum care before discharge (46% to 43%). Stillbirths reduced from 11(95% CI, 9-13) to 4(3-5) per 1000 births (p<0.001). Some practices did not improve even after sustained reinforcement. Commitment from state, engaging district officers, monitoring and feedback by external managers enabled supportive setting. The structured training and mentoring package, and periodic assessments delivered under supervision ensured the standards of mentoring. The mentoring model is acceptable, effective, less costly and scalable; appears sustainable if state commits to institutionalising a long-term mentoring with adequate monitoring. We conclude that the SCC-based mentoring and skill building program showed improvement in practices during childbirth while it sustained high levels of care during admission, but no improvement in postpartum care. The state needs to monitor and ensure continuous mentoring with required infrastructural support.

Effects of the World Health Organization Safe Childbirth Checklist on Quality of Care and Birth Outcomes in Aceh, Indonesia: A Cluster-Randomized Clinical Trial

Importance

To address major causes of perinatal and maternal mortality, the World Health Organization developed the Safe Childbirth Checklist (SCC), which to our knowledge has been rigorously evaluated only in combination with high-intensity coaching.

Objective

To evaluate the effect of the SCC with medium-intensity coaching on health care workers' performance of essential birth practices.

Design, Setting, and Participants

This cluster randomized clinical trial without blinding included 32 hospitals and community health centers in the province of Aceh, Indonesia (a medium-resource setting) that met the criterion of providing at least basic emergency obstetric and newborn care. Baseline data were collected from August to October 2016, and outcomes were measured from March to April 2017. Data were analyzed from January 2020 to October 2021.

Interventions

After applying an optimization method, facilities were randomly assigned to the treatment or control group (16 facilities each). The SCC with 11 coaching visits was implemented during a 6-month period.

Main Outcomes and Measures

For the primary outcome, clinical observers documented whether 36 essential birth practices were applied at treatment and control facilities at 1 or more of 4 pause points during the birthing process (admission to the hospital, just before pushing or cesarean delivery, soon after birth, and before hospital discharge). Probability models for binary outcome measures were estimated using ordinary least-squares regressions, complemented by Firth logit and complier average causal effect estimations.

Results

Among the 32 facilities that participated in the trial, a significant increase of up to 41 percentage points was observed in the application of 5 of 36 essential birth practices in the 16 treatment facilities compared with the 16 control facilities, including communication of danger signs at admission (treatment: 136 of 155 births [88%]; control: 79 of 107 births [74%]), measurement of neonatal temperature (treatment: 9 of 31 births [29%]; control: 1 of 20 births [5%]), newborn feeding checks (treatment: 22 of 34 births [65%]; control: 5 of 21 births [24%]), and the rate of communication of danger signs to mothers and birth companions verbally (treatment: 30 of 36 births [83%]; control: 14 of 22 births [64%]) and in a written format (treatment: 3 of 24 births [13%]; control: 0 of 16 births [0%]).

Conclusions and Relevance

In this cluster randomized clinical trial, health facilities that implemented the SCC with medium-intensity coaching had an increased rate of application for 5 of 36 essential birth practices compared with the control facilities. Medium-intensity coaching may not be sufficient to increase uptake of the SCC to a satisfying extent, but it may be worthwhile to assess a redesigned coaching approach prompting long-term behavioral change and, therefore, effectiveness.

Trial Registration

isrctn.org Identifier: ISRCTN11041580.

Effectiveness of the World Health Organization Safe Childbirth Checklist (WHO-SCC) in preventing poor childbirth outcomes: a study protocol for a matched-pair cluster randomized control trial

Background

Women delivering in health facilities in sub-Saharan Africa and their newborns do not always receive proven interventions needed to prevent and/or adequately manage severe complications. The gaps in quality of care are increasingly pointed out as major contributing factor to the high and slow declining perinatal mortality rates. The World Health Organization Safe Childbirth Checklist (WHO-SCC), as a quality improvement strategy, targets low cost and easy to perform interventions and suits well with the context of limited resource settings. In this matched-pair cluster randomized controlled trial, we assess the effectiveness of the WHO-SCC in improving healthcare providers’ adherence to best practices and ultimately improving childbirth outcomes.

Methods

This is a multi-country study. In each country we will carry out a matched-pair cluster randomized controlled trial whereby four pairs of regional hospitals will be randomized on a 1:1 basis to either the intervention or control group. A context specific WHO-SCC will be implemented in the intervention facilities along with trainings of healthcare providers on best childbirth practices and ongoing supportive supervisions. The standard of care will prevail in the control group. The primary outcome is a summary composite metric that combine the following poor childbirth outcomes: stillbirths, maternal deaths, early neonatal deaths, severe postpartum hemorrhage, maternal infections, early neonatal infections, prolonged obstructed labor, severe pre-eclampsia, uterine rupture in the health facility, eclampsia and maternal near miss. The occurrence of these outcomes will be ascertained in a sample of 2530 childbirth events in each country using data extraction. A secondary outcome of interest is the adherence of healthcare providers to evidence best practices. This will be measured through direct observations of a sample of 620 childbirth events in each country.

Discussion

Our study has the potential to provide strong evidence on the effectiveness of the WHO-SCC, a low cost and easy to implement intervention that can be easily scaled up if found effective.

Trial registration

The trial was registered in the Pan-African Clinical Trials Registry on 21st January 2020 under the following number: PACTR202001484669907. https://pactr.samrc.ac.za/TrialDisplay.aspx?TrialID=9662

Impact evaluation of a maternal and neonatal health training intervention in private Ugandan facilities

Global and country-specific targets for reductions in maternal and neonatal mortality in low-resource settings will not be achieved without improvements in the quality of care for optimal facility-based obstetric and newborn care. This global call includes the private sector, which is increasingly serving low-resource pregnant women. The primary aim of this study was to estimate the impact of a clinical and management-training programme delivered by a non-governmental organization [LifeNet International] that partners with clinics on adherence to global standards of clinical quality during labour and delivery in rural Uganda. The secondary aim included describing the effect of the LifeNet training on pre-discharge neonatal and maternal mortality. The LifeNet programme delivered maternal and neonatal clinical trainings over a 10-month period in 2017-18. Direct clinical observations of obstetric deliveries were conducted at baseline (n = 263 pre-intervention) and endline (n = 321 post-intervention) for six faith-based, not-for-profit primary healthcare facilities in the greater Masaka area of Uganda. Direct observation comprised the entire delivery process, from initial client assessment to discharge, and included emergency management (e.g. postpartum haemorrhage and neonatal resuscitation). Data were supplemented by daily facility-based assessments of infrastructure during the study periods. Results showed positive and clinically meaningful increases in observed handwashing, observed delayed cord clamping, partograph use documentation and observed 1- and/or 5-minute APGAR assessments (rapid scoring system for assessing clinical status of newborn), in particular, between baseline and endline. High-quality intrapartum facility-based care is critical for reducing maternal and early neonatal mortality, and this evaluation of the LifeNet intervention indicates that their clinical training programme improved the practice of quality maternal and neonatal healthcare at all six primary care clinics in Uganda, at least over a relatively short-term period. However, for several of these quality indicators, the adherence rates, although improved, were still far from 100% and could benefit from further improvement via refresher trainings and/or a closer examination of the barriers to adherence.

Adaptation and implementation of the WHO Safe Childbirth Checklist around the world

Background

The World Health Organization (WHO) published the WHO Safe Childbirth Checklist in 2015, which included the key evidence-based practices to prevent the major causes of maternal and neonatal morbidity and mortality during childbirth. We assessed the current use of the WHO Safe Childbirth Checklist (SCC) and adaptations regarding the SCC tool and implementation strategies in different contexts from Africa, Southeast Asia, Europe, and North America.

Methods

This explanatory, sequential mixed methods study—including surveys followed by interviews—of global SCC implementers focused on adaptation and implementation strategies, data collection, and desired improvements to support ongoing SCC use. We analyzed the survey results using descriptive statistics. In a subset of respondents, follow-up virtual semi-structured interviews explored how they adapted, implemented, and evaluated the SCC in their context. We used rapid inductive and deductive thematic analysis for the interviews.

Results

Of the 483 total potential participants, 65 (13.5%) responded to the survey; 55 completed the survey (11.4%). We analyzed completed responses from those who identified as having SCC implementation experience (n = 29, 52.7%). Twelve interviews were conducted and analyzed. Ninety percent of respondents indicated that they adapted the SCC tool, including adding clinical and operational items. Adaptations to structure included translation into local language, incorporation into a mobile app, and integration into medical records. Respondents reported variation in implementation strategies and data collection. The most common implementation strategies were meeting with stakeholders to secure buy-in, incorporating technical training, and providing supportive supervision or coaching around SCC use. Desired improvements included clarifying the purpose of the SCC, adding guidance on relevant clinical topics, refining items addressing behaviors with low adherence, and integrating contextual factors into decision-making. To improve implementation, participants desired political support to embed SCC into existing policies and ongoing clinical training and coaching.

Conclusion

Additional adaptation and implementation guidance for the SCC would be helpful for stakeholders to sustain effective implementation.

Supplementary Information

The online version contains supplementary material available at 10.1186/s43058-021-00176-z.