Checklist Improves Health Practices in Childbirth

More women die in the developing world from complications during pregnancy and childbirth than from any other cause, according to the World Health Organization. But, a group of scientists thinks it can change that with the help of a simple paper checklist.

“We know when they’re dying – most deaths are clustered right around the time of birth for both moms and babies,” said Jonathan Spector, a research scientist at the Harvard School of Public Health, “and we know what they’re dying from.”

Spector said mothers die from bleeding, infection, obstructed labor, and complications of hypertension disorders, while babies die from infection, complications of premature birth, and asphyxia.

“The tragedy here is that these deaths could largely be averted if existing knowledge and practice could be applied,” he said.

In other words, doctors know how to prevent these killer complications from ever happening, and the measures are not complex or expensive.

For instance, one important way to avoid infection is “appropriate hand hygiene, which means washing hands with soap and water and wearing gloves prior to a vaginal exam,” Spector said.

“It sounds pretty straightforward, and I think, if you asked most birth attendants, they would say they were doing that each and every time.”

But, Spector said it turns out, “Everyone ends up being a bit fallible.”

In fact, a study at a health center in southern India showed health workers were missing quite a few steps. On average, they performed just a third of a list of 29 essential, routine practices.

In the study, researchers observed nearly 500 births from the time the woman was admitted to the hospital to the time she was discharged. The researchers were watching how often the birth attendants performed routine practices, which included everything from holding a family planning discussion to administering a dose of oxytocin to the mother within a minute after delivery, to prevent a possible hemorrhage.

The study showed that health workers were only doing an average of 10 of the 29 recommended tasks.

That figure saw rapid improvement, however, in the next phase of the study. The health workers were given a simple checklist – a one page document listing all 29 “essential practices.”

Spector said nothing on the checklist was new. Every item was something health workers were supposed to be doing already, based on existing guidelines, existing evidence, and expert consensus.

The only difference was that workers were now supposed to mark each item every time a task was completed.

In the nearly 800 births observed after the checklist was introduced, health workers performed an average of 25 out of the 29 recommended practices.

Spector said it is important to create systems that encourage health workers to follow recommended guidelines.

“In every setting around the world, we know that health workers don’t always adhere to all the essential practices each and every time,” he said.

“There are a number of reasons for this. Sometimes the practice is simply too complex, sometimes there is an element of distraction. You can be in the middle [of a procedure] and be distracted by a question or comment from a coworker, any number of reasons why it doesn’t happen. But, it does [occur], even under the best of circumstances.”

Although the study was conducted in India, Spector said he expects the checklist to have similar results in Africa, where the WHO says nearly 600 women die from childbirth-related complications every day.

“The reasons why moms and babies die in Africa are very similar to the major killers in India,” Spector said, adding that researchers worked with collaborators in Mali, Nigeria, Tanzania, and South Africa to help develop the checklist.

Researchers say they are still gathering data to determine whether the improvement in completing the tasks also led to a decrease in complications and deaths. They are currently implementing a larger study in 100 health centers across India.