Improving Quality of Care for Maternal and Newborn Health : Prospective Pilot Study of the WHO Safe Childbirth Checklist

Background: Most maternal deaths, intrapartum-related stillbirths, and newborn deaths in low income countries are preventable but simple, effective methods for improving safety in institutional births have not been devised. Checklistbased interventions aid management of complex or neglected tasks and have been shown to reduce harm in healthcare. We hypothesized that implementation of the WHO Safe Childbirth Checklist program, a novel childbirth safety program for institutional births incorporating a 29-item checklist, would increase delivery of essential childbirth practices linked with improved maternal and perinatal health outcomes. Methods and Findings: A pilot, pre-post-intervention study was conducted in a sub-district level birth center in Karnataka, India between July and December 2010. We prospectively observed health workers that attended to women and newborns during 499 consecutively enrolled birth events and compared these with observed practices during 795 consecutively enrolled birth events after the introduction of the WHO Safe Childbirth Checklist program. Twenty-nine essential practices that target the major causes of childbirth-related mortality, such as hand hygiene and uterotonic administration, were evaluated. The primary end point was the average rate of successful delivery of essential childbirth practices by health workers. Delivery of essential childbirth-related care practices at each birth event increased from an average of 10 of 29 practices at baseline (95%CI 9.4, 10.1) to an average of 25 of 29 practices afterwards (95%CI 24.6, 25.3; p,0.001). There was significant improvement in the delivery of 28 out of 29 individual practices. No adverse outcomes relating to the intervention occurred. Study limitations are the pre-post design, potential Hawthorne effect, and focus on processes of care versus health outcomes. Conclusions: Introduction of the WHO Safe Childbirth Checklist program markedly improved delivery of essential safety practices by health workers. Future study will determine if this program can be implemented at scale and improve health outcomes. Citation: Spector JM, Agrawal P, Kodkany B, Lipsitz S, Lashoher A, et al. (2012) Improving Quality of Care for Maternal and Newborn Health: Prospective Pilot Study of the WHO Safe Childbirth Checklist Program. PLoS ONE 7(5): e35151. doi:10.1371/journal.pone. 0035151 Editor: Philippa Middleton, The University of Adelaide, Australia Received January 24, 2012; Accepted March 8, 2012; Published Copyright: 2012 Spector et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Funding: This work was supported by grants from World Health Organization (WHO) and the Children’s Investment Fund Foundation (CIFF). WHO provided input on study design, data analyses, decision to publish, and preparation of the manuscript. WHO had no role in data collection. CIFF had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Competing Interests: AAG receives royalties for books and essays focused on patient safety and medicine. CL receives royalties for a book focused on healthcare management. All other authors have declared that no competing interests exist. This does not alter the authors’ adherence to all the PLoS ONE policies on sharing data and materials. * E-mail: jmspector@partners.org . These authors contributed equally to this work.