Lessons Learned from Implementing the WHO Safe Childbirth Checklist

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By: Kayla McGowan, Project Coordinator, Women and Health Initiative, Harvard T.H. Chan School of Public Health

To maintain momentum for maternal newborn health, we must share our successes and failures in improving health outcomes for moms and babies. This month, scientists at Ariadne Labs, a collaboration between Brigham and Women’s Hospital and the Harvard T.H. Chan School of Public Health, hosted a webinar to present their partner’s experience using the World Health Organization (WHO) Safe Childbirth Checklist (SCC) in Namibia. Participants discussed the development of the SCC, an implementation project that utilized the SCC, and key takeaways on using the checklist in other settings.

As Dr. Lisa Hirschhorn, Director of Ariadne’s Implementation and Improvement Science Platform and Associate Professor of Medicine at Harvard Medical School, emphasized, though the field of maternal newborn health has made remarkable progress in the last several decades, effective interventions are needed to further reduce maternal and neonatal mortality and prevent needless suffering. Even when preventative practices are identified, however, providers do not always know, remember, or have the supplies to implement them. Using checklists helps “free up” providers’ minds to respond to emergency situations if they arise.

The Safe Childbirth Checklist, a set of evidence-based birth practices addressing major causes of maternal death, intrapartum-related stillbirths, and neonatal deaths is designed around four pause points during childbirth: on admission; just prior to delivery; within one hour of birth; and before discharge. The SCC identifies preventative practices, such as handwashing and antibiotic preparation, to avoid or manage complications like infection, hemorrhage, and obstructed labor.

According to Dr. Katherine Semrau, Director of the BetterBirth Program, “The WHO Safe Childbirth Checklist can’t ever be implemented by itself … Simply dropping off a checklist and handing it over alone doesn’t create impact and doesn’t create uptake of this tool.” Like other checklists used by Ariadne Labs, the SCC relies on an accompanying implementation guide and a continuous human element.

Findings from preliminary research have revealed three key processes for implementing the SCC:

  • Engagement. Gaining buy-in from key stakeholders and establishing a team to support implementation are crucial steps to utilizing the SCC. Implementers must also adapt the SCC to meet local guidelines and protocols, such as adding more pause points in settings with high HIV prevalence.
  • Launch. Introducing the SCC in an official event, including a technical training, will build staff interest in using the checklist as a method of quality improvement.
  • Ongoing Support. Coaching staff by observing, encouraging, and providing constructive feedback will help shape new behavior and improve performance.

Dr. Leonard Kabongo, obstetrician and quality improvement expert at Gobabis District Hospital, Namibia’s largest government-run district hospital in the region, provided additional insight into effective use of the SCC. Prior to implementing the SCC, poor maternal and newborn health outcomes at the facility stemmed from poor adherence to essential safe childbirth best practices, like handwashing, among hospital staff as well as “poor integration of quality improvement strategies in routine clinical practice.” Dr. Kabongo led a 22-week project, including a pilot and implementation stage, which increased birth attendant use of the SCC from an average of 46 percent in the pilot phase, to an average of 86 percent in the implementation period. During this time, staff also increased individual best practices, such as proper handwashing, tray preparation, and administration of oxytocin. Use of the SCC has contributed to significant reductions in maternal mortality in the hospital.

According to a member of the maternity staff at Gobabis District Hospital,

“After realizing through the checklist that oxytocin was not administered after delivery in a specific case, we understood why the woman experienced PPH [postpartum hemorrhage]. That scenario convinced us that using the checklist was important.”

5 Lessons learned from using the SCC in Namibia

According to Dr. Kabongo, facilities planning to utilize the SCC should learn from the following findings:

  1. Leaders must be part of the process. According to Dr. Kabongo, leaders should be immersed in all stages of SCC implementation and ensure a safe environment where staff can share their experiences and feedback.
  2. Anticipate initial resistance. Staff may perceive the checklist as having a heavy paper burden, but this will diminish as they understand and experience its value.
  3. Collect and share observational data to empower staff. During the 22-week project, Dr. Kabongo would discuss data from the previous week at weekly meetings with maternity staff. Staff could then see firsthand the impact of using the checklist, which led to increased uptake.
  4. Facilitate peer-to-peer coaching. According to Dr. Kabongo, “As a quality improvement champion, you need to coach by example.” The next step is to help staff coach other staff. Dr. Kabongo’s team moved from an audit approach to supportive supervision, focusing on the importance of teamwork.
  5. Support quality improvement champions. Identify committed individuals who can help lead peer-to-peer coaching. As Dr. Kabongo found, “Quality improvement requires quality leadership.”

Missed the webinar?

Watch the webinar.

Download the slideshow.

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Learn more about the launch of the checklist and the Safe Childbirth Checklist Case Study in Namibia.


For more information on Safe Childbirth Checklist implementation, please email info@ariadnelabs.org.

Download the Safe Childbirth Checklist and Implementation Guide in English, French or Spanish here.