WHO Releases Guidelines for Reducing Maternal, Newborn Deaths

Troy Brown, RN

December 08, 2015

Researchers at the World Health Organization (WHO) have identified four key times around childbirth when maternal and newborn deaths are most likely to occur in health facilities. The WHO has used this knowledge to develop checklists for each period, with critical actions that healthcare professionals should take to avoid health crises.

"Far too many women and children are still dying in childbirth from preventable causes often linked to poor quality of care," Marie-Paule Kieny, PhD, WHO assistant director-general of health systems and innovation, said in a WHO news release. "The WHO Safe Childbirth Checklist will help health care workers follow the essential care standards for every birth."

These steps are needed because most maternal and newborn deaths happen around the time of delivery, usually within the first 24 hours after childbirth, and most of these are preventable.

More than 130 million infants are born each year. About 303,000 of those births result in the mother's death, 2.6 million end in stillbirth, and another 2.7 million newborns die within the first 28 days after birth. Most of these fatalities occur in settings with few resources and often without skilled birth attendants.

The WHO's new Safe Childbirth Checklist and Implementation Guide address the primary causes of maternal and newborn complications and deaths, including postpartum hemorrhage, infection, obstructed labor, preeclampsia, and birth asphyxia.

The checklist incorporates existing evidence-based WHO guidelines and recommendations into a single, easy-to-use bedside tool designed to facilitate compliance with best practices, including improved communication around the period of delivery.

"We know from other health disciplines, such as surgery, that a properly implemented checklist of best practices encourages a culture of teamwork, problem solving, and discipline that leads to better care," said Atul Gawande, MD, MPH, Ariadne Labs executive director, surgeon, author, and Harvard School of Public Health professor in Boston, Massachusetts.

"We believe this simple and low-cost tool can make a difference for women and infants in settings around the world," he said.

Four Critical Pause Points

The checklist covers four "pause points" that occur at specific periods during a healthcare worker's normal workflow: (1) when the mother is admitted to the labor and delivery unit, (2) just before the woman begins to push or undergoes a cesarean delivery, (3) within 1 hour after birth, and (4) shortly before the mother and infant are discharged from the hospital.

These pause points occur at times when staff have the best chance of preventing complications, but also at times likely to be most convenient with respect to their workflow.

For example, immediately after birth, the healthcare worker should check the mother's uterus to ensure that she is not bleeding excessively and does not have an infection. The healthcare worker should also ensure that the mother has begun breast-feeding and skin-to-skin contact and that those are progressing well.

Before the mother and baby are discharged, the birth attendant should ensure that both have remained at the facility for at least 24 hours after birth, that the mother's blood pressure is within normal limits, and that the baby is eating well.

The WHO consulted with healthcare practitioners, patient safety experts, maternal and newborn healthcare experts, and patients from around the world to develop the checklist.

The checklist was initially piloted in nine countries in Africa and Asia, after which it was field-tested in Karnataka State, India. Since the checklist was introduced, adherence to recommendations at each delivery increased from an average of 10 of 29 practices before initiation of the checklist to an average of 25 of 29 after introduction of the checklist.

From 2012 to 2015, the WHO launched the Safe Childbirth Checklist Collaboration, during which 34 groups from 29 countries field-tested the tool. Lessons learned during field testing were used to develop the implementation guide.

A randomized, controlled trial, known as BetterBirth, is being conducted in more than 100 hospitals in India to measure the checklist's impact on maternal, fetal, and newborn survival and severe maternal harm. The trial will be completed in 2017.

This fall, all countries will implement Sustainable Development Goals From 2016-2030. This set of goals includes substantially reducing maternal and newborn deaths globally. To that end, the WHO and its partners have begun a new Global Strategy for Women's, Children's and Adolescents' Health 2016-2030, which will provide a roadmap with evidence-based investments and actions for ending preventable deaths and improving the well-being of women, children, and adolescents.

"In agreeing to the Sustainable Development Goals and the new Global Strategy, world leaders have shown that the health of women, children and adolescents are top priorities," Flavia Bustreo, MD, WHO assistant director-general for family, women's and children's health, said in the WHO news release. "Now it is time to translate this strategy into action. The Safe Childbirth Checklist is a practical tool that could contribute to improving the quality of care of mothers and newborns."

The checklist was developed and tested in collaboration with Ariadne Labs, a joint center of Brigham and Women's Hospital and the Harvard T. H. Chan School of Public Health, with support from the Bill and Melinda Gates Foundation.

The WHO is developing French and Spanish editions of the checklist and the implementation guide, and will develop the tools in other languages as well.

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