Implementing the WHO Safe Childbirth Checklist: lessons learnt on a quality improvement initiative to improve mother and newborn care at Gobabis District Hospital, Namibia

Abstract

BackgroundAlthough there are many evidence-based practices that reduce the risk of maternal and neonatal mortality around the time of birth, there remains a gap between what is known and the care received. This know-do gap is a source of preventable maternal and perinatal deaths and is the focus of improvement efforts in many countries. Following an increase in perinatal and maternal deaths, Gobabis District Hospital initiated a quality improvement (QI) initiative to increase adherence to these WHO Safe Childbirth Checklist (SCC)-targeted essential birth practices (EBPs).MethodsWe implemented the SCC with support from leadership, coaching and organisational redesign. Implementation was led by a facility champion supported by a QI team and adapted through a series of three 8-week Plan–Do–Study–Act (PDSA) cycles.ResultsDuring the 6-month period, we observed an improvement of average EBPs delivered from 68% to 95%. We also found reductions in perinatal mortality rates from 22 deaths/1000 deliveries to 13.8/1000 deliveries largely due to a drop in fresh stillbirths.ConclusionWe conclude that replicating the programme is feasible, acceptable and effective in areas where gaps exist, but it requires local leadership, ongoing coaching and adaptation through PDSA cycles.

Strengthening intrapartum and immediate newborn care to reduce morbidity and mortality of preterm infants born in health facilities in Migori County, Kenya and Busoga Region, Uganda: a study protocol for a randomized controlled trial

“…First, the WHO developed the Safe Childbirth Checklist which includes 29 EBPs that focus on maternal and neonatal outcomes at four pause points – on admission to the facility, at the time of pushing (or before cesarean delivery), soon after birth (within 1 h) and at discharge. This checklist has been used in a variety of LMICs contexts, including India, Sri Lanka, and Namibia [9–11]. In Namibia, the authors reported an increase of EBPs from 68% to 95% over a 6-month period, as well as a reduction in perinatal mortality from 22 to 13.8 deaths/1000 deliveries [11].…”

“…This checklist has been used in a variety of LMICs contexts, including India, Sri Lanka, and Namibia [9–11]. In Namibia, the authors reported an increase of EBPs from 68% to 95% over a 6-month period, as well as a reduction in perinatal mortality from 22 to 13.8 deaths/1000 deliveries [11]. A more recent report from the Better Birth Trial in India revealed that despite an increase in use of EBPs, outcomes did not improve [12], suggesting that the checklist alone may be insufficient in some contexts.…”

The Three-Gap Model of Health Worker Performance

“…Unfortunately, it is also clear that training is not adequate because performance suffers from a know-do gap: health worker knowledge of correct protocol is often well above performance [16,17,18,19,6,20]. However, knowing that a knowdo gap exists does not help us know how to close the gap.…”

Integration of the Opportunity‐Ability‐Motivation behavior change framework into a coaching‐based WHO Safe Childbirth Checklist program in India

“…The SCC is organized to drive change at four critical moments (or pause points): on admission, before delivery, within 1 hour after delivery, and before discharge. Initial studies have demonstrated an association between SCC use and improved adherence to EBPs …”

“…Initial studies have demonstrated an association between SCC use and improved adherence to EBPs. [9][10][11] Evidence from quality-improvement initiatives has shown the importance of integrated interventions to change both provider behavior and the healthcare system. When done well, supportive supervision, clinical mentorship, and coaching can be effective in changing provider behavior in a variety of settings, increasing the rate of skill transfer or adoption and generating more sustained improvement in performance than training alone.…”