Hospitals are invited to contribute to testing checklist for safer births

BMJ 2013; 346 doi: (Published 10 May 2013) Cite this as: BMJ 2013;346:f3067
  1. Anne Gulland
  1. 1London

Institutions around the world are being urged to take part in a study to assess a World Health Organization initiative to make birth safer for mothers and babies. A pilot study in India showed that it was effective.

WHO launched its Safe Childbirth Checklist last November ( This week it organised a webinar urging research institutions around the world to use the checklist and to feed back results.

Itziar Larizgoitia, from WHO’s patient safety programme, said that the checklist would be finalised and officially launched in 2015.

She said, “It’s extremely important that the checklist is a tool that contributes to improvements in best practice and that it is capable of being used by different countries around the world. It has to be usable and effective in diverse circumstances.”

The idea for the checklist was born after the success of the Surgical Safety Checklist, published by WHO in 2009, which aimed to reduce morbidity and mortality from surgery in middle and low income countries,1 said Severin Von Xylander, from WHO’s department of maternal, newborn, child, and adolescent health.

“Could we apply a similar mechanism to an event which we know puts two individuals at risk? This was how the idea was born,” he said.

The guidelines are intended for use in low and middle income countries where haemorrhage, sepsis, and hypertensive disorders are the leading causes of maternal mortality. Among babies the leading causes are neonatal sepsis and birth asphyxia.

The checklist has 29 questions or “pause points” that should be considered at four points during childbirth: on admission, before pushing or a caesarean section, one hour after birth, and at discharge. Questions include whether the mother or baby needs antibiotics, whether particular supplies are available, and whether breast feeding has been established.

A pilot study conducted in a rural hospital in India in 2010 found much better adherence to basic safety practices after the checklist was implemented.2 The study of 499 births that occurred before implementation of the checklist and 795 births afterwards found that on admission of the patient appropriate hand hygiene took place in 1% of cases before implementation and 98% afterwards. It also showed that the cord was cut with a sterile blade in 12% of cases before implementation and 99% afterwards. However, the sample size was not big enough to assess whether the checklist saved lives. A randomised control trial is being carried out in 120 hospitals in Uttar Pradesh, led by the Harvard School of Public Health.

Although the guidelines are primarily aimed at middle and low income countries, there is no reason why more developed systems should not use them, said Larizgoitia. The Surgical Safety Checklist, originally intended for poorer countries, is used in many European countries.

“This is not something that just one person can do. It’s about the system being changed,” she said.

Priya Agrawal, an obstetrician who helped develop the childbirth checklist and a researcher on the pilot study in India, said that the beauty of the checklist was its simplicity. Training in its use should not take more than a few hours out of a health professional’s workload.

“It’s simple and it’s low cost, as it can be written down on a single piece of paper,” she said. Agrawal interviewed the nurses who implemented the checklist, who told her how they used it to encourage managers to act when supplies were short.

“They [the nurses] said that they could write down that they wanted to give oxytocin but that they couldn’t give it because there wasn’t enough,” she said. “The checklist is simple, but it’s important to realise that you cannot just download it and go. You need leadership, you need someone to be a checklist champion, and you need supplies,” she said.

Nurses taking part in the study showed it to colleagues in other birth facilities who found it difficult to implement on their own, said Agrawal. “This is not just something that one person can do. It’s about the system being changed,” she said.


Cite this as: BMJ 2013;346:f3067


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