Quality (317) The WHO safe childbirth checklist after 5 years: future directions for improving outcomes

16 February, 2022

This Comment in The Lancet Global Health reviews global experience with the WHO safe childbirth checklist (SCC), and emphasises that 'the SCC has been most effective when implemented as part of larger quality improvement initiatives'. Citation, selected extracts and a comment from me below.

CITATION: The WHO safe childbirth checklist after 5 years: future directions for improving outcomes

Rose L Molina et al

Lancet Global Health 2022; Comment| volume 10, issue 3, e324-e325, march 01, 2022

Open Access Published: March, 2022 DOI: https://doi.org/10.1016/S2214-109X(21)00556-8


The WHO Safe Childbirth Checklist (SCC), designed out of the patient safety movement, addresses the major causes of morbidity and mortality surrounding childbirth and was publicly released in 2015. The SCC consolidates essential birth practices that should be done for every woman and infant. Although the SCC was designed as a job aide for frontline professionals, the SCC alone is not what drives safety and quality. Rather, the SCC has been most effective when implemented as part of larger quality improvement initiatives that enhance the enabling environment — policies and practices that enable success—for childbirth care.

The BetterBirth trial, the largest trial of the SCC to date, showed that SCC implementation with an 8-month coaching programme and continuous data feedback led to significant improvements in adherence to evidence-based practices in primary-level facilities in Uttar Pradesh, India, but did not lead to a reduction in maternal or perinatal morbidity and mortality... there might need to be a high threshold of adherence to a set of checklist items to have an impact on outcomes, requiring quality improvement infrastructure and an enabling environment.

Evidence highlights the impact of the SCC on perinatal outcomes when implemented as part of broader quality improvement interventions... Identifying the key complementary initiatives to improve maternal outcomes is a critical next step...

There remains an unfinished agenda to identify adaptations—both clinical and operational—to ensure key practices are done for every birthing person, every time...

Regarding optimal implementation pathways for the SCC, much remains unknown. Different strategies (such as coaching and incentives) might be needed to motivate behaviour change for particularly difficult practices...

The SCC remains an important patient safety tool for high-reliability systems. Yet the optimal adaptations and implementation pathways to impact outcomes in a given context remain elusive... Now is the time to identify the optimal complementary intervention packages and contexts for the SCC to improve maternal and newborn safety, quality, and outcomes.

COMMENT (NPW): In our discussions on Quality we have raised the question of whether and how quality improvement approaches need to be adapted for low-resource settings. It would be interesting to know what is the relative impact of the SCC in low-resource versus higher-resource settings. To what extent are health workers in low-resource settings able to implement the SCC?

I note that one of the main conference tracks for the upcoming ISQuaconference (Brisbane, October 2022) is on 'Quality and safety in low-resource settings'. I think this is a key area for the future.

Best wishes, Neil

Neil Pakenham-Walsh, HIFA Coordinator, neil@hifa.org www.hifa.org