Checklist Improves Childbirth Practices

Larry Hand

May 17, 2012

May 17, 2012 — Delivery of essential healthcare practices during childbirths improved 150% at a hospital in India after birth center care providers began using a simple, 29-item checklist, according to an article published online May 16 in PLoS One.

Jonathan M. Spector, MD, from the Department of Health Policy and Management, Harvard School of Public Health (HSPH), Boston, Massachusetts, and colleagues conducted a pilot study of birth practices at a hospital in Karnataka, India, in 2010. They observed practices before checklist implementation between July and September (499 birth events) and after checklist implementation between September and December (795 birth events).

"The rate of successful delivery of essential practices at each birth event increased from an average of 10 of 29 practices at baseline (95%[confidence interval (CI)] 9.4, 10.1) to an average of 25 of 29 practices afterwards (95%CI 24.6, 25.3; p<0.001)," the researchers write.

"There was significant improvement in the delivery of every practice except maternal referral," they add.

The World Health Organization's (WHO's) Safe Childbirth Checklist, tested in the current study, contains 29 terse reminders of essential steps for providers during childbirth. The reminders are divided into 4 critical times during a birth event, from admission to discharge.

The checklist is designed to help alleviate the major causes of maternal and child deaths and stillbirths and can be altered to fit locally specific requirements. In 2008, the WHO assembled a group of researchers to develop the checklist. The concept was based on previous checklist programs that have been credited for reducing deaths and complications in surgery and intensive care medicine. Investigators subsequently tested the childbirth checklist in 10 African and Asian countries before the newly published pilot study was launched.

During the pilot study at the Karnataka birth center, adoption of the checklist was voluntary, and individual care providers decided for themselves whether to use it. However, Dr. Spector and colleagues report that program was adopted and implemented rapidly by the local healthcare providers, with little cost.

For each study period, observers watched the caregivers 24 hours daily, for at least 6 days a week, during 3 periods: on admission, continuously from the time of pushing through 1 hour after birth, and on discharge. Monitored practices included assessment of infection risk, good hygiene, blood loss assessment, antibiotic administration, use of sterile devices, and referral when needed.

"Improved Maternal, Fetal, and Newborn Outcomes"

The checklist program led to "a marked increase in delivery of essential childbirth practices linked with improved maternal, fetal, and newborn outcomes," the researchers write.

"This is a significant step forward because it provides hope that use of this simple, low-cost tool can help birth attendants better adhere to universally accepted standards in childbirth care," senior author Atul Gawande, MD, professor in health policy and management at HSPH, lead advisor for WHO Patient Safety's childbirth and surgery safety programs, and a surgeon at Brigham and Women's Hospital, said in a press release.

The researchers cite 3 mechanisms by which the improvements were made: reinforcement for caregivers about a core set of practices, reminders to complete the practices at the correct time, and highlighting gaps in care that existed before checklist implementation. In addition, the researchers write, "[t]he local team seemed inspired by the checklist program and developed a personal interest in helping it to succeed."

To address a possible study weakness such as health workers' tendency to perform better when being observed, the researchers employed the same data collectors throughout, who observed the workers almost continuously, so the process would be as routine as possible.

The researchers conclude that although the program led to improved quality of care at this center, further study will determine whether such a system saves lives and reduces harm. About 350,000 maternal deaths, 1.2 million intrapartum-related stillbirths, and 3.1 million neonatal deaths occur each year in the world; the researchers contend that most are avoidable through intervention programs.

"The results of this study are the first evidence to suggest that the success we've seen with checklists in other health disciplines, for example in surgery, might also be applied to prevent avoidable childbirth-related deaths in low-income countries," Itziar Larizgoitia, coordinator in the Patient Safety Programme for the WHO, said in a press release.

This study was supported by the WHO and the Children's Investment Fund Foundation. Dr. Gawande reports receiving royalties for books and essays focused on patient safety and medicine. One coauthor reports receiving royalties for a book focused on healthcare improvement. The other authors have disclosed no relevant financial relationships.

PLoS One. 2012;7:e35151. Full text

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