Experience with a context-specific modified WHO safe childbirth checklist at two tertiary care settings in Sri Lanka

The aim of the study was to assess whether a more context-specific modified version of WHO Safe Childbirth Checklist (mSCC) would result in improved adoption rate.

A prospective observational study was conducted in University Obstetrics Unit at De Soysa Hospital for Women (DSHW), Colombo and two Obstetric Units at Teaching Hospital, Mahamodara, Galle (THMG), Sri Lanka. Study was conducted over 8 weeks at DSHW and over 4 weeks at THMG after introduction of the mSCC in 2017. The WHO SCC was in use at DSHW from 2013 until its replacement by the mSCC. Checklists were kept attached at admission and collected on discharge. Level of acceptance was assessed using a self-administered questionnaire at the end. Outcome measures were adoption rate (percentage of deliveries where mSCC was used and could be found), adherence to practices (mean percentage of items checked), response rate (percentage of staff members responded to questionnaire) and level of acceptance (percentage of "strongly agree/agree" in Likert scale to five questions regarding acceptance of mSCC). Responses were also taken to the open-ended question on barriers to implementation.

In DSHW, out of 606 births during study period, there were 329 live births in which the mSCC was used and could be found giving an adoption rate of 54.3%. In THMG adoption rate was 153/814 (18.8%). In DSHW, response rate for the questionnaire was 40.5% and in THMG, 40.0%. Level of acceptance was good among those who responded to the questionnaire. Mean (95% CI) adherence to the Checklist practices was 52.7% (44.1-58.5) in DSHW and 32.2% (24.5-39.1) in THMG with a range of 1-100% in both settings. Majority mentioned the lack of staff, lack of enthusiasm, inadequate training and advice on use of mSCC and lack of supervision from Ministry/institutional level. Majority suggested the involvement of medical doctors, removal of the need to place the signature and separate accountability to each 27-items and the desirability of proper training sessions regarding the mSCC.

Checklist-based interventions in maternity care cannot be expected to improve by merely making them context-specific. Other approaches should be explored to maximize its benefits.