TABLE 2. Implementation Experience of Coaches and Independent Observers on Implementing the WHO Safe Childbirth Checklist in Uttar Pradesh, India
Summary of Coach-Observed Adherence Over Intervention PeriodEssential Birth Practice ExampleAverage Adherence Level Observed by CoachAbsolute Difference Over Time (Observed by Coach)Qualitative Summary of Coaches' Implementation ExperienceSummary of Independent Observers' Findings
Minimal improvement (<15 percentage points) due to high initial adherenceSupply preparation before delivery (gloves, cord ligature, blade)98%, 98%, 97%6%, 5%, 8%Coaches used the SCC to encourage birth attendants and labor room staff to prepare and organize materials prior to deliveries or early in the day so that supplies were ready to use.Supply preparation remained consistent even when the coach was absent
Measuring baby's weight after birth93%9%Measuring a baby's weight is a standard requirement in birth registries and used to calculate Vitamin K dosage, thus weight was frequently taken. Additional pressure from families to know a baby's birth weight contributed to high adherence.Measuring a baby's weight remained consistent even when the coach was absent.
Minimal improvement (<15 percentage points) achievedBCG vaccine administration77%13%Incentives at the facility and district level to minimize waste may have contributed to less consistent administration of BCG and other vaccines. Each BCG vial contained 10 doses; birth attendants were observed to avoid administration unless a certain number babies were present to avoid wasting vaccines.N/A (not measured).
Oral polio vaccine administration87%3%
Moderate improvement (15 to 24 percentage-point absolute difference)Hand hygiene before delivery90%18%Coaches found that hand hygiene was more consistently done before delivery, compared with before a vaginal exam during admission.This behavior saw the greatest difference between coach and independent observer (92% vs. 36%).
Oxytocin administration within 1 minute of delivery92%19%Birth attendants noticed the effects of changing the timing and route of oxytocin administration—from IV administration to augment labor to IM administration immediately postpartum—which they felt contributed to decreased hemorrhage and decreased fetal distress.Moderate absolute difference (17 percentage points) when the coach was not present.
Skin-to-skin immediately after birth87%23%Coaches observed that birth attendants appreciated tangible improvements in babies' status from initiating skin-to-skin immediately, including better temperature regulation and easier initiation of breastfeeding.Minimal absolute difference (13 percentage points) when the coach was not present.
Greatest improvement
(≥25 percentage-point absolute difference)
Check mother for bleeding after delivery89%26%Coaches noted that birth attendants saw the value of routinely assessing bleeding in order to recognize hemorrhage early, when it is easier to treat.N/A (not measured).
Initiation of breastfeeding87%27%Coaches felt that they were able to reinforce the importance of this practice due to the clear governmental guidelines that promote breastfeeding.Moderate absolute difference (23 percentage points) when the coach was not present.
Skin-to-skin at 1 hour83%29%If skin-to-skin was not initiated immediately, coaches found it difficult to gain commitment to this practice, as birth attendants faced competing priorities of needing to complete birth-related paperwork and families' pressure to show the newborn to relatives waiting outside of the labor room.N/A (not measured).
Temperature measurement after delivery (mother, baby)86%, 81%30%, 36%Birth attendants commonly used their hand to subjectively feel if a patient had a fever and were satisfied with this method. Thermometers may have been broken or misplaced. Many facilities experienced unreliable electricity, and thermometers were difficult to read in dark rooms. Coaches found that it was challenging to gain commitment to this behavior.Major absolute difference in measurement of baby's temperature (48 percentage points) when the coach was not present. Independent observers did not document mothers' temperature after delivery.
Variable improvement in checklist useChecklist use
On admission
Before delivery
After delivery
Before discharge
More structured patient assessments that occurred on admission and within 1 hour after birth were conducive to SCC use. Just before delivery was an extremely busy time for birth attendants; birth attendants frequently regarded referring to a checklist as more of a burden or barrier to providing timely care at pause point 2. Because the SCC was a standalone document and not integrated into the existing patient record (bedhead ticket), it was easy to overlook. Coaches saw the importance of advocating to the heads of facilities to integrate the SCC into the bedhead ticket.Moderate to major absolute difference when the coach was not present (38 percentage-point difference in checklist use on admission, 62 percentage-point difference before delivery, 21 percentage-point difference after delivery). Independent observers were not present at discharge.
  • Abbreviations: BCG, bacille Calmette-Guérin; IM, intramuscular; IV, intravenous; SCC, Safe Childbirth Checklist; WHO, World Health Organization.