According to the World Health Organization (WHO), of the more than 130 million births occurring worldwide each year, approximately 303,000 end in maternal death, 2.6 million in stillbirth and 2.7 million in newborn death within 28 days of delivery. Most of these deaths take place in low-resource settings and are preventable with timely and appropriate interventions. However, providers do not always know, remember or have the supplies to implement these life-saving interventions, especially in emergency situations. Checklists remind health providers of necessary steps for routine deliveries as well as situations involving complications.
The WHO Safe Childbirth Checklist (SCC), 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.
Last month, scientists at Ariadne Labs, a collaboration between Brigham and Women’s Hospital and the Harvard T.H. Chan School of Public Health, hosted Implementing Checklists for Quality Improvement: Best Practices Along the Implementation Pathway – “Engage”, the second webinar in their interactive series dedicated to sharing lessons learned in implementing the SCC for quality improvement. Presenters explored how to ensure buy-in and identify relevant stakeholders, establish an implementation team and utilize best practices in checklist adaptation. Dr. Rosemary Ogu shared her team’s experience piloting a program using the Safe Childbirth Checklist in Port Harcourt, Nigeria.
Engaging staff and stakeholders
According to the Ariadne team, effective implementation of the SCC relies on three core processes: engaging staff and stakeholders, formally launching the checklist and providing ongoing support for the team. The following steps are crucial to the ‘engage’ process:
1. Determine program goals and gain buy-in.
According to Dr. Joanna Paladino, Assistant Director of Implementation, Serious Illness Care Program at Ariadne Labs, teams who plan to implement the SCC should first consider their overarching goals: “What do you hope to accomplish with the program?” “How will the checklist improve quality of care?” “What impact will it have on staff?” Dr. Paladino encouraged teams to define a collaborative mission statement and set clear program goals.
Another fundamental step in ensuring successful uptake of the SCC is to gain buy-in by building partnerships at the local, district, regional and national levels. Engaging leadership is also important as it shows the facility that implementing the checklist is a priority and helps ensure access to relevant resources. Moreover, according to Dr. Paladino, this step involves leveraging a collective effort:
“Engaging and gaining buy-in is about changing hearts and minds. It’s bringing people into this effort so you that you do this as a team and everyone owns it and has a voice in the work.”
Coordinating one-on-one conversations with team members is a highly effective way to gather feedback and convince team members of the SCC’s benefits. When considering whom to involve in this step, the Ariadne team abides by its guiding principle, “Everyone who will be touched by the intervention should be engaged in this work.” Do not avoid the skeptics. Speaking with those who may not be enthusiastic about the SCC helps teams work through challenges and strengthen their implementation strategy.
Dr. Ogu, an obstetrician gynecologist at the University of Port Harcourt Teaching Hospital in Nigeria, explained that her team knew poor quality of care was contributing to high maternal mortality rates at the hospital (in 2013, maternal mortality rates were 143 per 100,000 live births among registered patients and 7,857 per 100,000 live births among those who did not register for antenatal care). Thus, the team’s goal in using the checklist was to improve compliance with best practices among health care workers. Findings from focus group data show that as a result of piloting the SCC, midwives and doctors at the University of Port Harcourt Teaching Hospital in Nigeria felt better equipped to counsel patients, prepare for emergencies and remember all the steps necessary to provide high quality care.
2. Create an implementation team and identify a champion.
As Dr. William Berry, Ariadne Labs Chief Medical Officer and Director, Safe Surgery Program, emphasized, identifying a passionate champion is key to implementing the SCC in health facilities: “You need to find somebody who people look up to – it does not mean they need to be a boss or chief or supervisor … the person people go to for advice on the frontlines often makes a great champion, whether they hold a formal title or not.”
Dr. Berry also emphasized the importance of forming a multidisciplinary team representative of the various roles that will be affected by the SCC, including physicians, nurses, birth attendants, pharmacists, lab technicians, administrators and coaches.
3. Conduct a needs assessment.
According to Dr. Paladino, this step is often skipped but is a critical element of successful implementation. Teams should ask themselves what they need to be ready to implement the SCC, including leadership support, resources and system capabilities. They should also reflect on prior quality improvement experiences and perform gap analyses to identify which supplies, human resources, referral systems and funding sources are available or missing.
4. Adapt and own the WHO Safe Childbirth Checklist.
Most importantly, teams should take the core framework presented in the SCC and customize it for their specific setting. It is essential for leaders to read the checklist thoroughly and discuss each item with their team. The SCC is a tool that should be compatible with the natural workflow of each facility. As Dr. Berry articulated
“It’s not the WHO’s checklist – it’s the facility’s checklist … The workflow is built around the people and processes of those people. If you don’t respect those, the checklist will get put down.”
Watch the webinar and download the slides here.
Missed the first webinar in the series?
Read our summary post from the first webinar: Lessons Learned from Implementing the WHO Safe Childbirth Checklist.
For more information on Safe Childbirth Checklist implementation, please email firstname.lastname@example.org.
Download the Safe Childbirth Checklist and Implementation Guide in English, French or Spanish here.