By Katherine Semrau, Ph.D.
Growing up in West Tennessee, I have fond memories of going to see my grandparents with my family. Mind you, this trip
was not on a short car trip, bus or train ride. It was an eight-hour flight in a small Cessna with me, my sister, my mom and my father—who happens to be a part-time pilot. When we were young, my sister and I used to get so excited to fly. We would press our noses up against the window shortly after take off and watch the world fade beneath us. But as I got older, I became more curious about how my father flew the plane.
I remember a green notebook that sat on his lap while he flew. He would refer to it often throughout the flight… looking at the words in the notebook and checking the instrument panel in the plane and going back to the notebook. He did this several times during the flight– at important moments — like just before taking off, once we reached cruising altitude, and just before landing. At the time I did not know, but this was the manual of aviation checklists and it is used by pilots around the world. Neither did I know what a checklist was, nor know how important checklists would be in my professional life.
I am an epidemiologist at Brigham & Women’s Hospital; assistant professor at Harvard Medical School and director of the BetterBirth Program at Ariadne Labs. At Ariadne Labs, we focus on simple tools to solve complex problems at critical moments in people’s lives. My program, BetterBirth, focuses on the critical moment of childbirth and we are working on testing and spreading an implementation program for the WHO Safe Childbirth Checklist.
Now, let’s consider modern checklists. Not the grocery store list or the honey-do lists, although those may be important. I’m talking about checklists that really matter and impact people’s lives.
In the 1930s, military airplanes were being designed to go farther, faster and carry heavier loads. One of these planes was called the “flying fortress,” the most complex plane designed to date. To test this machine, a highly trained and experienced pilot took off in the plane and crashed to the ground. Upon review, no mechanical errors or engineering failures were found, rather it was human error/pilot error that caused the crash. The pilot had forgotten the simple task of unlocking the rudder and elevator controls on the plane; something all pilot should remember to do. The aviation industry realized that when flying these complex machines, it is easy to forget the most simple of tasks, and thus the manual of aviation checklists was born.
Now, the industry has had more than 60 years of successful development and implementation of checklists. With more than
3.2 billion airline passengers a year, and accident rate of three accidents per 1,000,000 departures, that would equate to a maternal mortality rate of 25 deaths/100,000 births—down from the current global average of 216 deaths/100,000.
I would argue that the global maternal and newborn health community has four lessons we can learn from aviation.
STANDARDIZATION: The aviation industry was on a quest to standardize operational procedures are essential for safety in all planes. The aviation checklist is beautiful in its simplicity and thoroughness. Individual items on the aviation checklists are essential; nothing is extraneous and ensures that all pilots are prompted to do or reminded of all the necessary tasks. Checklists are designed for critical moments in flying, including before takeoff and before landing.
Similarly, the WHO Safe Childbirth Checklist addresses four critical moments during childbirth: at admission, just before pushing, within one hour of delivery and at facility discharge. The behaviors on the WHO checklist address the biggest causes of mortality in women and newborns and are thus essential practices arising from evidence-based WHO guidelines. Thus, the first lesson we can take from the aviation industry is that the checklists are standardized and universal.
ADAPTATION: The second lesson we can learn about checklists from aviation is that checklists should be adapted. Aviation checklists are modified for the specific airlines culture and environment. The checklist used on a Delta airlines flight may look slightly different than the checklist used on SAS airlines. Language may be different or ordering of items may change, but the essential items are present.
We know in public health that one-size-fits-all programs rarely work. In the WHO Safe Childbirth Checklist, the standard essential practices are there, but the Checklist should be adapted for the local context. For example, in the work we are implementing in India with Population Services International, the checklist was adapted to include BCG tuberculosis vaccination for the newborn to align with Government of India guidelines. In settings of high HIV prevalence, the Checklist needs to be adapted to include HIV testing and treatment guidelines. Context matters; Checklists must be adapted to be functional.
NO TASK TOO SMALL: The third lesson we can learn from aviation is that no procedure or task is too small to include on the checklist. In 2006, a plane was taking off in the early morning darkness. There was construction at the airport, a short-staffed air traffic control tower, and a pilot who ended up on the wrong runway and crashed. Checking the runway is a simple task, so simple, it was never included on the before-takeoff checklists. After that, the aviation checklist was updated to include a reminder to check the runway.
In childbirth, some of the simplest tasks are the one most often not performed. Handwashing is one of these simple, yet often elusive behaviors. In our experience in India, less than 10 percent of birth attendants washed their hands prior to conducting a vaginal exam. It is the most basic of hygiene behaviors, but undone, the consequences may be severe for infection and sepsis. Even this simple task is included on the WHO Safe Childbirth Checklist.
IMPLEMENTATION MATTERS: The Fourth lesson to be learned from aviation is that how the checklist is introduced and implemented matters. The aviation checklists are part of all pilot’s training now and continued monitoring and support for use of checklist is standard. Today, any pilot will tell you that checklists are an essential part of aviation culture.
Checklists are implemented with consistency through training and coaching. Checklists are embedded in the rigorous simulator training pilots undergo to get their license. It is not just that the checklist is available, but that the checklist should be used for every flight, by every pilot, no exceptions. Further, Check Airmen, senior pilots with years of experience, fly along with pilots–junior and senior alike–and observe pilot behaviors. They provide feedback to the pilot about how they flew.
In the world of childbirth, the WHO Checklist can and should be included as part of training for nurses, midwives, ob/gyns and birth attendants. Our experience in India has taught us that peer coaching is a critical component of success. BetterBirth coaches, like the Check Airmen, observe and provide feedback to the birth attendant and help problem solve the deficiencies and celebrate the successes. Like Check Airmen, the coaching is never penalty based, rather it is through support and practice that implementation of the WHO Checklist has been adopted. With this adoption, we are seeing dramatic improvements in the basic quality of care provided to women and children in India.
Today, around the world, 800 women will die during childbirth. If an airplane crashed and killed 800 people, we would see this story on every newspaper and television screen. Every year, 300,000 women die in childbirth, 2.6 million stillbirths, and nearly 3 million newborns died in the first month of life. And the bigger tragedy in all those numbers is that the large majority of those deaths are preventable.
We know what causes maternal and newborn mortality. We know what to do to prevent these deaths. Use of the WHO Safe Childbirth Checklist will improve the quality of care and improve the practices of birth attendants around the world to ensure high quality and safe delivery. We cannot take an entire generation for this idea of Checklists to spread to childbirth. These essential birth practices should be given to every woman and every newborn no matter where they are in the world.
Katherine Semrau, Ph.D. is an epidemiologist and the director of the Ariadne Labs BetterBirth Program. This essay was first delivered at Women Deliver 2016 in a live Speaker’s Corner talk.