In early July, I attended, on behalf of the Maternal Health Task Force, the initial two-day consultation meeting on the development of a safe birth “checklist” co-organised by the WHO Patient Safety team in Geneva, Switzerland. (For more information regarding the meeting, read below.) Over a very hot two days, more than 60 experts in the area of safe clinical practice for maternal health discussed the issue of how to ensure maternal and newborn safety at the time of birth. The delegates represented all areas of the world and most WHO Regions. They hailed from Chile to India, Tanzania to Laos, New Zealand to Sweden and many countries, including the USA and UK in between. It proved to be a hot, busy, interesting and useful preliminary meeting.
The aim of the “safe child birth checklist programme” appears simple. That is, to ensure that every mother and her newborn baby has the best possible care throughout labour and delivery through the routine use of simple, proven measures to provide the highest quality clinical care, including stopping unnecessary procedures if necessary. The programme is based on the airline industry’s own risk assessment process with a standardised checklist that every pilot completes prior to take off to ensure that he/she doesn’t overlook or forget to do something, however routine. WHO has already adapted such an approach in one area, surgery, and published the in 2008, which is an instrument that promotes compliance with the completion of essential tasks that should be performed at the start, during and end of all operations. This one pager can be downloaded from the WHO website.
When it came to discuss developing a similar one pager that could be completed for intrapartum care things became a little more complicated. It is clear that if this is to be universally applicable throughout the world and in any setting then it needed to be just as relevant to a midwife in a rural health facility as to an obstetrician in a large teaching hospital in a developed country. And thus lively debates were had.
In the end it was agreed that, although much more work needed to be done to finalize such a list before piloting it in a number of areas, a set of common principles seemed to have been agreed. The first was that the check, or “pause” point, when staff have to take time out to assess and complete the list and risk assessment before actions need to be taken, went beyond intrapartum care to the initial assessment when a woman presented in labour to her discharge with the baby after delivery.Thus work is ongoing to develop a simple check list to cover necessary actions at all of these three points. The first, on presentation in labour, is designed to check if she is in labour, if she has risk factors that would require her to best be delivered in a higher level facility, and to then transfer her, is for when the mother first presents in labour. Also at this point the discussions recommended that the mother and her birth partners were fully consulted and that every proposed action and the reason for it was to be explained to them. This simple concept for women based care has never been part of such a guideline before and, if included in the final list, will represent a huge leap forward for many women of the world. Once in established labour the checklist is going to focus on the use of the partogram and other techniques in normal labour to identify when actions may need to be taken if a problem develops, and organising the birth kit etc so that everything has been pre- planned and is ready and in place at the time of delivery to ensure both mother and baby receive the best possible care. The third pause point will be after delivery and before going home. Here there will be the necessary checks for mother and baby and advice given on signs and symptoms of illness or when to come back etc.
As you can imagine, even this simple concept generated long discussions, as there are so many guidelines and protocols already in existence. However, by the end of the second day the group had reached a consensus on the way forward in that they supported the three pause point approach and the general issues that needed to be covered. The WHO team are now taking away the considerable comments and flip charts and preparing a first draft for further comment which should be circulated soon. I understand that before it is finally signed off it will be available on the web for open comment and review.
Watch this space for more on this exciting initiative.
On July 8th and 9th the WHO Patient Safety Programme convened an international meeting of experts in Geneva to address the possibility of developing a checklist that would help to ensure the delivery of minimum care standards to mother and baby around the time of childbirth. Meeting delegates came from diverse backgrounds with expertise in advocacy, academia, frontline experience, and newborn and maternal health. Representatives were present from all WHO regions. The meeting was further advanced by the extensive support of WHO colleagues. Following a detailed discussion regarding the transferability of the checklist concept to childbirth there was clear consensus that such a path was feasible, practical, and necessary. Technical groups started the work of defining potential “pause points” – steps in care at which detection and correction of error, or preventive action, could be associated with a significant reduction in harm. An early draft Safe Childbirth Checklist was populated, with the major causes of maternal and neonatal mortality used as starting points. The draft checklist developed in Geneva is now going through a dynamic process of revision according to comments raised by meeting participants and other experts. Informal testing will help to inform additional modifications. When a ‘final’ draft is agreed upon, more formal testing will be vital to evaluating its efficacy.