BackgroundFacility-based childbirth in low-resource settings has increased dramatically over the last two decades, yet quality of care gaps persist and mortality rates remain high. The World Health Organization (WHO) Safe Childbirth Checklist, a quality improvement tool, promotes systematic adherence to practices known to save lives and prevent harm during childbirth. MethodsWe conducted a matched-pair, cluster-randomized controlled trial in 60 pairs o facilities across 24 districts of Uttar Pradesh, India to test the effectiveness of the BetterBirth program, an 8-month coaching-based implementation of the Checklist, on a composite outcome of 7-day maternal/perinatal mortality and maternal morbidity. Outcomes—assessed 8-42 days post-partum—were compared between study arms adjusting for clustering and matching. We also compared birth attendants’ mean adherence to 18 essential birth practices in 15 matched pairs of facilities at 2 and 12 months after intervention initiation. ResultsOf 161,107 eligible women, we enrolled 157,689 (98%) and determined 7-day outcomes for 157,145 (99.7%) mother-newborn dyads. Of 4888 observed births, birth attendants’ adherence to practices was significantly higher in the intervention (I) than control (C) arm (I: 73% vs. C: 42% at 2 months, p≤0.01; I: 62% vs. C: 44% at 12 months, p≤0.01). However, we found no difference in the composite outcome (I: 15.1% C: 15.3%, RR: 0.99, 95% CI: 0.83-1.18, p=0.90). ConclusionThe coaching-based WHO Safe Childbirth Checklist program produced increased adherence to some essential birth practices, but did not reduce morbidity and mortality. (Clinical Trials #NCT02148952; The Bill & Melinda Gates Foundation)

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BackgroundThe BetterBirth trial tested the effect of a peer coaching program around the WHO Safe Childbirth Checklist for birth attendants in primary-level facilities in Uttar Pradesh, India on a composite measure of perinatal and maternal mortality and maternal morbidity. This study aimed to examine the adherence to essential birth practices between two different cadres of birth attendants—nurses and auxiliary nurse midwives (ANMs)—during and after a peer coaching intervention for the WHO Safe Childbirth Checklist.MethodsThis is a secondary analysis of birth attendant characteristics, coaching visits, and behavior uptake during the BetterBirth trial through birth attendant surveys, coach observations, and independent observations. Descriptive statistics were calculated overall, and by staffing cadre (staff nurses and ANMs) for demographic characteristics. Logistic regression using the Pearson overdispersion correction (to account for clustering by site) was used to assess differences between staff nurses and ANMs in the intervention group during regular coaching (2-month time point) and 4 months after the coaching program ended (12-month time point).ResultsOf the 570 birth attendants who responded to the survey in intervention and control arms, 474 were staff nurses (83.2%) and 96 were ANMs (16.8%). In the intervention arm, more staff nurses (240/260, 92.3%) received coaching at all pause points compared to ANMs (40/53, 75.5%). At baseline, adherence to practices was similar between ANMs and staff nurses (~ 30%). Overall percent adherence to essential birth practices among ANMs and nurses was highest at 2 months after intervention initiation, when frequent coaching visits occurred (68.1% and 64.1%, respectively, p = 0.76). Practice adherence tapered to 49.2% among ANMs and 56.1% among staff nurses at 12 months, which was 4 months after coaching had ended (p = 0.68).ConclusionsOverall, ANMs and nurses responded similarly to the coaching intervention with the greatest increase in percent adherence to essential birth practices after 2 months of coaching and subsequent decrease in adherence 4 months after coaching ended. While coaching is an effective strategy to support some aspects of birth attendant competency, the structure, content, and frequency of coaching may need to be customized according to the birth attendant training and competency.Trial registrationClinicalTrials.gov: NCT2148952; Universal Trial Number: U1111–1131-5647.

Implementation of the WHO Safe Childbirth Checklist with peer coaching resulted in >90% adherence to 35 of 39 essential birth practices among birth attendants after 8 months, but adherence to some practices was lower when the coach was absent.

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(N Engl J Med. 2017;377(24):2313–2324) The Safe Childbirth Checklist, created by the World Health Organization, is a practical tool encompassing a bundle of 28 essential birth practices. In the present study, the authors performed a large cluster-randomized trial of the BetterBirth program, which involves a coaching-based implementation of this checklist, to determine whether or not facility-based birth adherence to this checklist improved evidence-based care. The authors hypothesized that, if implemented at the cluster level, the intervention would reduce the composite outcome of stillbirth, early neonatal death, maternal death, or maternal severe complications during postpartum days 0 to 7.

This study indicates that circulatory diseases, injury and malignant diseases have become the major causes of death in India, after infections. Members of social classes 1-3 died more often due to circulatory diseases and members in lower social classes died more often due to infections. Urbanization with rapid changes in diet and lifestyle in various social classes, and possibly aging of the population seem to be responsible for the double burden of diseases, related to under- and over-nutrition, causing death in a developing economy. Monitoring of blood pressure and heart rate around the clock for 7 days, with data analysed chronobiologically can detect abnormal circadian patterns associated with a large increase in cardiovascular disease risk, greater than hypertension itself, allowing the institution of prophylactic treatment. Such prehabilitation may be particularly useful to curb the increasing burden of cardiovascular diseases in both developed and developing countries.

The BetterBirth Program relied on carefully structured coaching that was multilevel, collaborative, and provider-centered to motivate birth attendants to use the WHO Safe Childbirth Checklist and improve adherence to essential birth practices. It was scaled to 60 sites as part of a randomized controlled trial in Uttar Pradesh, India.