Sikar, India — The use of a safe childbirth checklist by health providers in four facilities was shown to lead to remarkable improvements in the quality of health services for mothers and newborns—underscoring the benefits of a quality of care tool that is practical, effective and easily applicable.
This field test was a precursor to the rollout of the Safe Childbirth Checklist (SCC) program. Jhpiego is providing technical assistance to theGovernment of Rajasthan (GoR) to implement this program in public sector health facilities. The Children’s Investment Fund Foundation (CIFF) is providing the funding support for the program.
The SCC includes 29 items to help service providers remember to perform all the essential safe care practices during childbirth. The checklist targets major causes of maternal mortality, such as postpartum hemorrhage, severe infections, hypertensive disorders and obstructed labor; childbirth-related stillbirths; and causes of neonatal mortality like birth asphyxia, infection and complications of prematurity.
The four facilities participating in the pilot project were chosen to assess the feasibility of introducing the checklist in various settings. They included the district hospital in Sikar, two community health centers and initial referral sites in Srimadhopur and Ajitgarh, and a community health center in Reengus.
In preparing for the field test, Jhpiego conducted a two-day training of trainers (TOT) to orient them on the checklist, the content of the training for service providers, and basic training skills. These trainers, who were from the government health department, then trained all of the service providers from the pilot facilities to leverage existing resources and establish self-sustaining mechanisms. Jhpiego provided supportive supervision throughout the training process.
The field test, which concluded in the last week of September, was successful in testing the basic implementation approach, usability of the checklist, general design and appropriateness of content in the context of Rajasthan. Results of the pilot were encouraging. All providers started using the checklist upon introduction, but the providers who had participated in the orientation to the tool were found to be using it more appropriately than those who had not.
Both oriented and non-oriented staff nurses reported improvement in practices following checklist use, such as appropriate use of antibiotics and the recording of temperature and blood pressure in mothers and babies. Oriented staff nurses also reported improvement in practices such as appropriate use of oxytocin during the third stage of labor, which helps prevent postpartum hemorrhage. As a result of the SCC, the availability of supplies in the labor room also improved. The oriented nurses agreed that the checklist helped them remember all essential activities related to safe childbirth and to perform them correctly.
Other key lessons learned during the field test follow:
- Buy-in from clinical and administrative leaders increases the potential for adoption of the SCC checklist by the staff in the facility;
- Orientation of all staff—including clinical and administrative leaders—is crucial to the success of the program;
- Use of the SCC requires a mechanism for post-training follow-up and support.
With the field test successfully completed, its results will be used to improve the implementation plan, checklist design, reporting tools and data-recording formats. A rapid assessment is to follow at all intervention and control sites to collect baseline information for the program. Upon completion of the rapid assessment, the intervention sites will be prepared for the subsequent implementation of the SCC program.
The SCC program will use a quasi-experimental design to determine whether implementation of the SCC in birthing sites in Rajasthan leads to improved adherence to safe care practices for childbirth and subsequent reduction in neonatal mortality. This program will be implemented in approximately 100 health facilities in selected intervention districts over a period of approximately one year and the results will be compared with approximately 100 control facilities. Documented learning from implementation of the SCC and results from the evaluation of its impact will be shared with the government and disseminated at various forums to inform scale-up strategies. The Public Health Foundation of India (PHFI) is the collaborating agency working to evaluate SCC effectiveness in target facilities.