Clinicians from around the world are interested in finding tools to improve the quality of the care they provide to women and infants during childbirth. Ariadne Labs has partnered with implementers in over 30 countries across the world to integrate the WHO Safe Childbirth Checklist into their current health system. Each region is extremely diverse – politically, economically, and socially. Ariadne Labs offers customized coaching and technical assistance to facilitate success. As each of our partners implement, we try to understand their successes and challenges in order to improve our solutions and share lessons learned with the wider community.
In 2014, Dr. Ayda Abdien Hago Taha and her team were selected to be part of the WHO collaborative for testing and implementing the WHO Safe Childbirth Checklist in Khartoum, Sudan. They recently completed their research, and Emily George, Clinical Implementation Specialist, spoke with them about their experience.
Can you describe the region of Sudan where you were working and why you wanted to implement the WHO Safe Childbirth Checklist?
Sudan is the third largest country in Africa and is a multiracial, multicultural nation distributed along 18 states and more than 180 localities. Around 40 million people live in Sudan; 70% of those people live in rural areas. Around 60% of births take place in facilities and the remaining 40% take place in homes. Midwives are relied upon to perform most births in each of these places. We were hoping that by implementing the checklist, we could expand coverage of our midwife services and enhance the care provided to mothers, regardless of where they deliver. We decided to pilot this project in the biggest maternal and referral hospital in Khartoum, Sudan. This hospital has over 35,000 deliveries per year.
Describe the intervention and how the checklist was used.
As outlined in the implementation guide, we started by engaging leaders within the Khartoum State Ministry of Health and administrative and clinical leaders within the hospital. Through several discussions with these leaders, we outlined the purpose and goals of implementing the checklist. Leaders at both levels expressed their commitment and support to testing the checklist at the hospital. If the checklist proved to be a useful tool for enhancing maternal care, the intent was to modify it and spread it to other Sudanese healthcare settings.
We started at the hospital level by collecting baseline data via observations and medical records review. Medical officers were selected to observe which practices on the checklist were already being performed. These findings, as well as opportunities for improvement and recommendations were communicated to the Khartoum State Ministry of Health and to the administrative and clinical leaders at the hospital. Time was given to the hospital to address these areas before starting checklist implementation.
After this, we conducted a training for all midwives and physicians practicing at the hospital. We covered all elements of the checklist and provided skills workshops on things like proper hand hygiene practices and methods of blood loss assessment after delivery. At this point, we began using the checklist in practice at the hospital.
What were some interesting challenges you faced during this intervention and how did you overcome them?
Despite our large training, there were several consultants rounding through the hospital with varying degrees of commitment to the checklist and frequent turnover of trained staff. To address this challenge, we tried to provide frequent trainings on how to use the checklist.
We also faced challenges with the quality managers who were overseeing the checklist implementation. Many of them lacked the authority to influence the behaviors of the physicians and midwives. Lastly, through implementation of the checklist, we saw many gaps in our infrastructure (e.g. lack of supplies) that were difficult to address in our short implementation time.
What were your key lessons learned? Are there any outcomes you can share?
Following checklist introduction, observers found that midwives used it 98% of the time, while doctors used it only 15% of the time. When the checklist was used, we saw a significant increase in adherence to the evidence-based practices for safe delivery.
The checklist had both direct and indirect effects. It not only facilitated the delivery of best childbirth practices, but it indirectly highlighted weaknesses in the hospitals’ inputs and processes. This type of change in culture and quality can be achieved, but it takes a lot of time. Many things have to be in place in order to see sustained practice change, which should eventually impact overall maternal and child health outcomes. We believe successful implementation of the checklist can be attained if the following elements are fulfilled:
- Leadership commitment and engagement
- Assessment of facility readiness to implement the checklist
- Establishing action plans to cover the gaps identified
- Starting in a smaller, more controlled setting
- Involving key figures as champions who are respected by their colleagues
- Using peer-to-peer coaching methods to increase adherence to practices
- Taking more time for implementation (at least 6-12 months)
- Empowering Quality Managers to ensure sustainability
— Written by Emily George, RN, BSN, MPH