Using the WHO Safe Childbirth Checklist to Improve Essential Care Delivery as Part of the District -Wide Maternal and Newborn Health Quality Improvement Initiative, a Time Series Study

Abstract

Background: Care bundles are a set of three to five evidence-informed practices which, when performed collectively and reliably, may improve health system performance and patient care. To date, many studies conducted to improve the quality of essential birth care practices (EBPs) have focused primarily on provider- level and have fallen short of the predicted impact on care quality, indicating that a systems approach is needed to improve the delivery of reliable quality care. This study evaluates the effectiveness of integrating the use of the World Health Organization Safe Childbirth Checklist (WHO-SCC) into a district-wide system improvement collaborative program designed to improve and sustain the delivery of EBPs as measured by "clinical bundle" adherence over-time.Methods: The WHO-SCC was introduced in the context of a district-wide Maternal and Newborn Health (MNH) collaborative quality of care improvement program in four agrarian Ethiopia regions. Three "clinical bundles" were created from the WHO-SCC: On Admission, Before Pushing, and Soon After Birth bundles. The outcome of each bundle was measured using all- or- none adherence. Adherence was assessed monthly by reviewing charts of live births.A time-series analysis was employed to assess the effectiveness of system-level interventions on clinical bundle adherence. STATA version 13.1 was used to analyze the trend of each bundle adherence overtime. Autocorrelation was checked to assess if the assumption of independence in observations collected overtime was valid. Prais-Winsten was used to minimize the effect of autocorrelation.Findings: Quality improvement interventions targeting the three clinical bundles resulted in improved adherence over time across the four regions. In Tigray region, adherence to “On Admission” bundle was increased monthly on average by B =1.39 (95% CI; 0.47 - 2.32; P<0.005).Similarly, adherence to the “Before Pushing” bundle in Southern Nations, Nationalities and People’s (SNNP) region increased monthly on average by B = 2.3 (95% CI; 0.89 - 3.74; P<0.005). Conclusion: Use of the WHO-SCC paired with a system-wide quality improvement approach improved and sustained quality of EBPs delivery. Further studies should be conducted to evaluate the impact on patient-level outcomes.

Promising practices for adapting and implementing the WHO Safe Childbirth Checklist: case studies from India and Rwanda

“…1 There is increasing evidence that the SCC is a vital tool in reducing perinatal mortality when implemented as part of broader quality improvement initiatives, such as enhanced supply chains in India 2 and technical training, qual-ity improvement collaboratives, and data quality assurance in Kenya and Uganda. 3 Over the past 5 years, there has been increasing adaptation and implementation of the SCC in a variety of settings, 4 including Brazil, [5][6][7] Ethiopia, 8,9 Indonesia, 10 and Italy. 11 With this uptake of the SCC, there is an opportunity to identify promising practices regarding SCC adaptation, implementation and evaluation.…”