Implementation of the World Health Organization Safe Childbirth Checklist in lower-middle-income settings was associated with higher adherence to evidence-based birth practices and lower stillbirth rates when used in environments that supported compliance, according to a meta-analysis of three cluster randomized trials in India, Indonesia, and Pakistan reported by Lennart Christian Kaplan, PhD, of Georg-August-University of Göttingen, Germany, in JAMA Network Open.
The analysis pooled data from trials conducted between 2014 and 2017 and included 169,511 births, 6,298 directly observed deliveries, and supply assessments from 163 facilities. Primary facilities were located in Uttar Pradesh, India; basic emergency obstetric care facilities in Aceh, Indonesia; and primary and secondary health centers in Khyber Pakhtunkhwa, Pakistan.
The trials evaluated locally adapted implementations of the World Health Organization (WHO) Safe Childbirth Checklist (SCC), a tool designed to guide birth attendants through 28 evidence-based practices (EBPs) at 4 pause points during childbirth care: admission, before delivery, shortly after birth, and before discharge..
In India, the 8-month SCC program included facility engagement, a launch event, and tapered coaching. Indonesia’s 6-month intervention involved 11 coaching visits, while Pakistan’s 12-month program provided light-touch external monitoring, skills training, and supply assessments.
Evidence-Based Practice Adherence
In Ffacilities assigned to the WHO SCC, EBP demonstrated higher adherence to EBP. Adherence increased by approximately four practices in intention-to-treat analysis and by six practices in the complier average causal effect (CACE) analysis, representing a 24 percentage point increase in adherence to the 15 essential birth practices..
Overall, adherence to the 15 essential birth practices increased by 24 percentage points with WHO SCC implementation.
Mortality Outcomes
Across the full study sample, mortality outcomes were not found todid not significantly differ between intervention and control facilities.
However, in the subsample of intervention facilities where observations were conducted, stillbirth rates were lower by nearly 10 per 1,000 births in intention-to-treat analysis and by about 15 per 1,000 births in the CACE complier average causal effect analysis.
“We identified substantial associations between the SCC and increasing application of EBPs, especially at admission and after birth, as well as reduction in stillbirths when considering adherence and heterogeneity in the analysis,” the researchers concluded. “To realize the full potential of the SCC, implementers and policymakers need to understand better what quality infrastructure (supplies, technical skills, and shared accountability) is necessary to create an enabling environment that supports sustained SCC use.”
The authors noted that checklist effectiveness may depend on health system infrastructure, including adequate supplies, trained staff, and accountability mechanisms that support consistent use of the checklist.
Disclosure: For full disclosures of the researchers, visit jamanetwork.com.
Source: JAMA Network Open
