With the introduction of the WHO Safe Childbirth Checklist to health facilities in two districts of a German-supported project aims to reduce the maternal and newborn mortality in Pakistan’s Khyber Pakhtunkhwa province.
Quality assurance and patient safety measures can markedly improve the delivery of maternal and newborn care services without increasing costs. This is why Germany supports the introduction of the WHO Safe Childbirth Checklist to health facilities in two districts of Pakistan’s Khyber Pakhtunkhwa province.
The main causes of maternal and newborn mortality are well-known and many can be prevented by relatively simple and inexpensive interventions. Especially in low resource settings like Pakistan, the introduction of quality assurance and patient safety measures can markedly improve the delivery of essential maternal and newborn care without increasing the facilities’ running costs. This is why German Development Cooperation supports the Nowshera and Haripur districts of Khyber Pakhtunkhwa province in introducing the WHO Safe Childbirth Checklist to all their public health care facilities and to community midwives.
The importance of bridging gaps in maternal and newborn health care
Dr Shazia Haroon knows only too well how difficult it can be to ensure good quality maternal and newborn care. As the sole obstetrician at the Mian Rashid Hussain Shaeed Memorial hospital in the Nowshera district of Khyber Pakhtunkhwa, her work is vital and sometimes exasperating. ‘We lose too many mothers and too many babies unnecessarily’ she explains. In practice, women with obstetric complications often arrive at her hospital with little information about their condition and at a stage when the problems are already quite far advanced and difficult to treat successfully.
According to Dr Shazia Haroon, many of the resulting maternal and newborn deaths are at least partly due to simple oversights and a lack of consistency early on in the treatment process. In particular, she describes how community midwives and staff in primary care facilities sometimes are too slow to make referrals or fail to recognise problems and carry out basic diagnostic tests. As a caring and scrupulous physician, it is clear that these gaps in the quality of treatment are a profound source of frustration to her.
However, thanks to a new project to implement the WHO Safe Childbirth Checklist, this situation could soon be a thing of the past. By synthesising a range of best practices into a simple bedside tool, the Checklist aims to help health care workers to improve the quality of care around childbirth and minimise complications and deaths. For Dr Haroon, the benefits are clear. ‘Most of the time I lack the information that I need’ she explains. ‘Implementing the Checklist will help to identify problems early on and make sure that the right decision is taken at the right time.’
Many maternal and newborn deaths are preventable
Reducing maternal and newborn mortality is an important priority for the Department of Health in Khyber Pakhtunkhwa. Whilst there has been some reduction in maternal deaths in the last 20 years, recent estimates from the Population Council suggest that the maternal mortality ratio remains high (Population Council, 2014). There are also substantial numbers of newborn deaths and estimates from the Pakistan Demographic and Health Survey suggest that the neonatal mortality rate (i.e. deaths the first 28 days of life) has in fact remained unchanged for the past twenty years (National Institute of Population Studies, 2013).
|Table 1 Key mortality and maternal and newborn health care indicators for Khyber Pakhtunkhwa
|Maternal Mortality Ratio (per 100,000 live births)
|Neonatal Mortality Rate (per 1000 live births)
|Infant Mortality Rate (per 1000 live births)
|Antenatal care (%)
|Skilled birth attendance (%)
|Notes: Estimates are based on data from the Pakistan Demographic and Health Surveys (PDHS) for 2006-07 and 2012-13. *2012-13 maternal mortality ratio was not estimated by the survey. The quoted estimate was produced by the Population Council. Source: Population Council, 2014
In general, the majority of maternal deaths occur during labour or the 24 hours following childbirth, and most newborn deaths are concentrated within the first week of life. The main causes of these deaths are well-known and can be prevented if staff recognise key warning signs and follow the correct treatment procedures. However, health workers in resource-poor settings like Khyber Pakhtunkhwa often struggle to remember these processes and have trouble carrying them out in the correct sequence.
A simple tool to improve the quality of maternal and newborn health care
In 2008 the World Health Organization (WHO) started to develop a checklist-based tool to address these difficulties. The resulting Safe Childbirth Checklist (see references at the end of the article) translates a range of known best practices into a simple format that health workers can use in their daily work. The Checklist is still in development, however, the pilot edition contains 29-items that address the main causes of morbidity and mortality around the time of childbirth. Each item on the list prompts the health worker to consider a critical action that, if missed, could lead to complications or death.
Extensive usability testing has already been carried out with more than 30 implementation projects spread across all six of the WHO regions. Overall the Checklist has been found to improve the quality of maternal and newborn health care. However, these initial experiences also suggest that it is important to ensure that the Checklist is well-adapted to local conditions and is implemented in a manner that encourages health workers to use and promote the Checklist (WHO, 2013).
A pioneering project to implement the Safe Childbirth Checklist in Pakistan
On behalf of the Federal Ministry for Economic Cooperation and Development (BMZ), the Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ) GmbH has partnered with the University of Göttingen to develop an innovative project, which carefully adapts and introduces the Safe Childbirth Checklist whilst simultaneously evaluating the overall implementation process. Although the Checklist was primarily developed for health professionals working in secondary care health facilities, the new project aims to introduce this tool to all public health care facilities and community midwives in the Nowshera and Haripur districts of Khyber Pakhtunkhwa province.
By choosing to introduce the Checklist to community midwives and primary health care workers, the project has significantly expanded the scope of the intervention and its capacity to improve health care quality in the selected districts. This is clearly desirable, however, the inclusion of these health workers also necessitates some additional measures to ensure that the implementation is a success.
Since mid-2015, the German supported Reproductive, Maternal and Newborn Health Project has been engaged in an extensive process to adapt the Checklist to the local context, as well as to community midwives and different types of health care facilities. The adaptation of the Checklist is crucial to the success of the project. Nevertheless, existing implementation experiences suggest that simply applying the adapted Checklist is unlikely to result in quality improvements unless those using the tool fully appreciate the underlying clinical logic and are able to use it effectively.
Addressing this issue head-on, the project is currently developing a new preparatory course for community midwives and primary health care workers, which combines training about the Safe Childbirth Checklist with standard training on delivery skills and Emergency Obstetric and Newborn Care. Providing community midwives and health workers in primary care facilities with this training should help to ensure that health workers in Nowshera and Haripur are well-informed about the Safe Childbirth Checklist and are able to use the tool effectively in their day-to-day work.
Since there are currently no other standardized training packages that integrate these three elements, the project will also seek to validate this course so that it can be transferred to other contexts where the Checklist is being implemented.
From early 2016 onwards, the Safe Childbirth Checklist will be rolled out to all public health care facilities and community midwives in these two districts of Khyber Pakhtunkhwa. To allow a comparison between facilities which have and have not benefitted from the intervention, the project will initially only introduce the Checklist to selected “intervention” health facilities and community midwives. However, following a period of data collection and reporting, it will then roll-out the Checklist to the remaining “control” facilities and community midwives by the end of the year.
This so-called phase-in randomized controlled trial design will enable researchers at the University of Göttingen to carry out a robust evaluation of the implementation process, which can be used to help subsequent initiatives to implement the Safe Childbirth Checklist successfully.
A potential turning point for maternal and newborn health care in Pakistan?
The planned implementation of the Safe Childbirth Checklist has the potential to substantially improve the quality of maternal and newborn health care in Nowshera and Haripur. However, some stakeholders are already optimistic that the benefits could spread further. At a recent technical working group meeting in Islamabad, Dr Faisal Khan Zada enthusiastically describes how the Checklist should streamline the referral process and help government facilities to provide more integrated care.
To assure the sustainable use of the tool, he believes that it is essential to integrate a validated training module into the existing course curriculum for community midwives. As the district coordinator for Maternal, Newborn and Child Health in Haripur and Abbottabad, Dr Faisal Khan Zada has a good overview of the conditions at facilities across the province and is convinced that ‘success in Haripur and Nowshera could definitely lead to the implementation of the Checklist in other areas in the North.’
A similar belief in the broader benefits of the project’s work is also shared by WHO’s National Professional Officer for Maternal, Newborn and Child Health, Dr Zareef Uddin Khan. Whilst conscious of the many logistical and cultural considerations that need to be taken in to account, Dr Zareef Uddin Khan is upbeat about the potential impact of project’s work. In particular, by adapting a Checklist that is ‘very simple and acceptable to the health provider’ he points out that the project creates ‘a good opportunity to improve health care quality in Pakistan as a whole.’
Only time will tell whether the introduction of the Checklist will meet these high expectations. However, by developing transferable training materials and combining the introduction of the Safe Childbirth Checklist with robust implementation research, the project has already ensured that its experiences will help to promote high quality maternal and newborn health care in Pakistan and other low- to middle-income countries.
by Susan Ramsay
- Population Council (2014) Khyber Pakhtunkhwa Population – 2014. Facts At-A-Glance. New York, Population Council
PDF | 272 KB | accessible
- WHO (2013) WHO Safe Childbirth Checklist Programme. An Overview. Geneva, World Health Organization
PDF | 461 KB | accessible
- Research protocol: Evaluating the impact of the WHO Safe Childbirth Checklist on the Quality of Care and Birth Outcomes in Public Health Facilities and among CMWs
PDF | 6 MB | accessible
- Presentation at Technical Working Group Meeting: Implementing the WHO Safe Childbirth Checklist
PDF | 2 MB | accessible
- Fact Sheet Reproductive, Maternal and Newborn Health Project (RMNHP)
PDF | 677 KB | accessible