URC Helps Develop Safe Childbirth Checklist to Improve Maternal and Newborn Care

URC, through the USAID Health Care Improvement Project, has contributed to the World Health Organization’s (WHO’s) Safe Childbirth Program, of which a key component is to develop and test a universally applicable Safe Childbirth Checklist. URC staff participated in a 2009 international expert consultation to develop a first draft of the checklist and supported its field testing in Mali in 2010.  

Each year, 350,000 women die around the time of childbirth, and 4.3 million newborns are born dead or die shortly after birth. Many of these deaths are preventable by applying highly effective, proven, and affordable health care practices. Unfortunately, such interventions are not consistently applied in every delivery—for reasons that range from an inadequate health workforce to overwhelmed staff who may unintentionally omit essential interventions around childbirth. 

Applying Checklists to Improve Quality of Services around Childbirth

The WHO Safe Childbirth Checklist, which is yet to be published, promotes routine delivery of highly effective interventions at critical “pause points” that occur during every routine delivery: 1) upon admission of a woman in labor to a maternity, 2) at the time she begins to push (or prior to Cesarean delivery), 3) immediately after delivery, and 4) before discharge from the maternity. The 29-item bedside checklist includes simple steps to prevent when possible or promptly detect and manage the major causes of 1) maternal deaths (bleeding, infection, obstructed labor, and hypertensive disorders), 2) intrapartum-related stillbirths that are related to inadequate labor and delivery care, and 3) newborn deaths that are related to trouble breathing, infection, and complications of prematurity. Developed in collaboration with the WHO Department of Maternal, Child and Adolescent Health; the Harvard School of Public Health; and other partners, the checklist will support frontline health workers to deliver the highest quality of maternal and newborn care to achieve the best outcomes for the mother and child.

Positive Results from Field Testing the Safe Childbirth Checklist

URC contributed to a seven-country feasibility testing of the Safe Childbirth Checklist in 2010 by supporting phase one of its testing in the maternity unit of the Regional Hospital in Kayes, Mali. The purpose of this phase was to further develop the draft Safe Childbirth Checklist through the knowledge and feedback of providers working in maternities in high-priority regions (that is, regions with high maternal and neonatal death rates).  Responses from providers ranged from the usability of this checklist in real life to aspects of the checklist that were the most useful to suggestions on clarifying or deleting some listed items and guidance on promoting the use of this checklist. The testing results contributed to the development of the revised prototype of the Safe Childbirth Checklist that could be used in the next phase—a rigorous, single-center testing— to evaluate its impact in a range of maternity settings in low-, middle-, and high-income countries.

The results of phase two testing—recently published in PLoS One by Dr. Jonathan M. Spector and colleagues—demonstrate that the checklist helped staff in a sub-district hospital maternity in Karmataka, India, improve delivery of best practices. The study evaluated adherence to the 29 essential practices that target prevention and management of major causes of childbirth-related mortality, such as hand hygiene and immediate administration of a uterotonic, a drug that reduces heavy bleeding after birth. The primary outcome measured was the rate of delivery of these 29 practices by health workers before and after introduction of the checklist. Delivery of these practices at each birth increased from an average of 10 out of 29 before the checklist’s introduction to an average of 25 out of 29 (p<0·001), with significant improvement in 28 of the 29 practices. 

Checklists Emerging as a Simple and Powerful Tool

Historically, checklists have been routinely used in aviation to standardize and ensure pilots’ completion of vital tasks. Increasingly, patient safety experts are adopting lessons learned from applying checklists in aviation and other industries to improve health care and outcomes for patients. An analysis led by renowned patient safety expert Dr. Atul Gawande of errors reported by surgeons in three prominent U.S. teaching hospitals revealed that critical care omissions happened even in the most sophisticated and well-equipped settings.

Under the leadership of the WHO Patient Safety program—whose aim is to “coordinate, disseminate and accelerate improvements in patient safety worldwide,” several checklists have been or are being developed as part of broader safety programs to improve best practices and reduce harm for a range of priority health conditions.  

The Surgical Safety Checklist, one of the first checklists developed as part of a WHO Patient Safety program, helps surgical teams (surgeons, anesthesia providers, and nurses) to verify essential actions at critical points in every surgery regardless of setting (prior to induction of anesthesia, prior to skin incision, and prior to leaving the operating room). In an eight-city study across low-, middle-, and high-income settings, use of that checklist was associated with a significant decrease in in-hospital complications and deaths during surgery in all eight sites (Haynes et al. 2009). The checklist has now become a global standard of surgical care supported by the WHO Safe Surgery Saves Lives program.  

Following the success of the surgical checklist, the WHO Patient Safety program launched work on several additional checklists, including one for health care workers treating patients with pandemic influenza A (H1N1) and another for providers managing trauma; the latter was developed in collaboration with the WHO Department of Violence and Injury Prevention and Disability. Phase 3 of this SCC testing – a large randomized controlled trial funded by the Bill and Melinda Gates Foundation– is underway in Uttar Pradesh, India, to evaluate the impact of the Safe Childbirth Checklist on maternal and newborn health outcomes. Results of this study are expected by 2015. 

Looking Ahead

URC is advancing strategies and approaches to improve the quality of health care for a broad range of high-burden health problems in low- and middle-income countries. For many years, URC has successfully helped health care systems in these countries introduce supportive tools, such as clinical care checklists and pictorial job aids, as one element of its approach to improve the performance of health workers and caregivers. Although a checklist alone is unlikely to produce sustainable impact on patient outcomes, the anchoring of a clinical care checklist within a strong implementation program is a powerful strategy for accelerating improved health care and outcomes, as evidenced by the WHO Surgical Safety program and other successful checklist-associated experiences (see Haynes et al. 2009; Provonost et al. 2006 and 2010; and Dixon-Woods et al. 2011). The elegant simplicity of a user-friendly checklist that standardizes, prioritizes, and aligns critical actions within predictable phases of a complex health care process makes checklists an important tool for supporting health care improvement in all income settings. URC will partner with WHO Patient Safety through the Applying Science to Strengthen and Improve Systems (ASSIST) project to roll out use of the checklist in Sub-Saharan Africa starting next year.

November 05, 2012
Regions/ Countries