Making WHO Safe Childbirth Checklist work in Bangladesh - A study to identify ways for uptake and sustained use

Despite significant improvement in maternal and newborn health, globally high levels of deaths concentrated around the time of delivery still remain. Efforts to further curb the rate have been directed at increasing the coverage of skilled birth attendants, especially in facility settings. The quality of care in health facilities therefore needs urgent attention to further end preventable maternal and neonatal morbidity and mortality.

Previous studies have shown that a large number of childbirth related deaths can be attributed to unhygienic and dangerous delivery practices. Good practice from birth attendants is important to improve childbirth related complications for both mother and the child, yet well recognised gaps in maternal and newborn care practices at birthing facility still exist. Minimum care standards and best practices for safe delivery have been extensively described; however, globally there has been no universal unifying guideline. In 2008, the World Health Organization (WHO) developed a 29-item checklist as a childbirth quality improvement tool, with the goal to assist frontline health care workers in reducing the number of adverse events that occur during childbirth. This tool is called WHO Safe Childbirth Checklist (WHO SCC) and is used to remind and help health workers adhere to essential childbirth practices known to be associated with improved maternal, foetal and neonatal health. WHO SCC has been previously piloted in various low-income settings and holds the potential to address challenges in existing low quality of care in childbirth practices.

In the current study, a quasi-experimental study was conducted in Jhenaidah and Magura District Hospitals (DH) in Bangladesh. The projectaimedtocomparetheadherencetobest practiceswhenWHO SCCwasused alone, comparedtowhenWHO SCCplussupportivesupervisionwasused.In addition, the study also identified facilitators and barriers in the implementation of WHO SCC in Bangladesh setting.

The study initially observed the childbirth practices of nurses and midwives in the baseline for three months between April–June 2014. Following the three-month baseline observation, the WHO Safe Childbirth Checklist (WHO SCC) was introduced. The nurses and midwives in both DHs were trained extensively on the use of WHO SCC. In Jhenaidah, a supervisory team was formed at the DH where additional intervention of supportive supervision was implemented. The study team were encouraged to conduct the day to day supportive supervision and to hold monthly meetings where all the staff from the delivery wards would meet and discuss the problems which arose in their daily delivery practices. In the intervention phase, deliveries were observed for a period of five months (July–November 2014) after the introduction of WHO SCC, leading to a total of eight months of field work. At the end of the study, qualitative data collection was conducted to explore study participants’ opinion regarding the implementation of the checklist and supportive supervision.

The study was funded by the Maternal Health Task Force at the Harvard T.H. Chan School of Public Health from the Bill and Melinda Gates Foundation through icddr,b. The study was implemented in partnership with icddr,b as well as participation of the WHO SCC collaboration.

• An expert consultation meeting was arranged among the investigators, study advisors, obstetricians,neonatologists, and public healthexperts from different organisations where each item of the WHO SCC checklist was discussed on its necessity and appropriateness in Bangladesh setting. This helped in adapting WHO SCC in Bangladesh context.
• Findings revealed that the activities of nurses with the checklist significantly increased to cover as many as 25 essential practices, including checking the mother for symptoms of infections and pre-eclampsia, arranging for supplies for vaginal examinations, discussing family planning options, counselling on exclusive breast feeding, and advising follow-up visits
• Study findings were been shared with MHTF during a dissemination workshop held in Dubai in 2015.
• A policy brief is being published by MHTF based on the study findings.