Compliance With the WHO Safe Childbirth Checklist at a Tertiary Care Hospital in Pakistan: A Closed-Loop Clinical Audit

TL;DR

This study evaluated how well a hospital in Pakistan followed the WHO Safe Childbirth Checklist before and after an educational intervention.

Contribution

The study provides real-world evidence of SCC compliance and improvement in a Pakistani hospital through a closed-loop audit and training.

Findings

Compliance with the checklist increased from 58.3% to 78.3% after the educational intervention.

The most significant improvements were observed in admission, before pushing or cesarean, and after birth phases.

Specific items like breastfeeding with skin-to-skin contact and family-planning counseling showed notable increases in compliance.

Abstract

Background: The World Health Organization (WHO) Safe Childbirth Checklist (SCC) is a 29-item instrument aimed at standardizing the key maternal and neonatal safety practices. However, there is a scarcity of data on real-world SCC compliance in Pakistan. The purpose of the study was to determine the baseline adherence to the WHO SCC at the Federal Postgraduate Medical Institute in Lahore, Pakistan, carry out an educational intervention, and gauge improvements after the intervention.

Methods: A prospective, closed-loop clinical audit was performed between December 1, 2023, and February 15, 2024. A pre-intervention cycle (Cycle 1) was used to determine baseline SCC adherence by observing 60 consecutive deliveries. An educational workshop, involving item-by-item demonstrations, team-communication role-plays, and the placement of laminated checklists at every pause point, was conducted among obstetricians, midwives, and nurses on December 31, 2024. Post-intervention compliance was then audited by a second cycle (Cycle 2) that sampled 60 consecutive deliveries. All 29 SCC items were noted in terms of “Yes/No” completion by trained auditors at the four pause points. Quantitative tests were carried out to determine the change in complete and phase-by-phase compliance between the study periods.

Results: The compliance from completed checklists increased from Cycle 1 by 35 (58.3%) to Cycle 2 by 47 (78.3%). The largest improvements were seen on admission from 40 (70.0%) to 50 (86.7%), before pushing or cesarean from 35 (58.3%) to 52 (86.7%), within one hour after birth from 32 (53.3%) to 51 (85.0%), and before discharge from 33 (55.0%) to 50 (80%). The largest item-specific increases were seen in breastfeeding with skin-to-skin contact, from 38 (63.3%) to 49 (81.7%), and the discharge-planning item, namely family-planning counseling, from 33 (55.0%) to 43 (71.7%).

Conclusion: The well-organized educational program had a significant effect on WHO SCC compliance in the tertiary care hospital in Pakistan. To achieve lasting change and minimize avoidable maternal and neonatal harm, the audit-feedback cycles and leadership involvement will be needed on a regular basis, as well as the incorporation of the SCC into regular clinical practice.