# The World Health Organization Safe Childbirth Checklist on Essential Birth Practices and Perinatal Mortality: A Meta-Analysis

## TL;DR

A global health checklist improved birth practices and reduced stillbirths in some cases, but didn't consistently lower overall mortality.

## Contribution

The study shows the WHO Safe Childbirth Checklist increases evidence-based practices and lowers stillbirth rates in specific settings.

## Key findings

- Use of the WHO Safe Childbirth Checklist increased evidence-based practice adherence by 24 percentage points.
- Stillbirth rates were 9.76 per 1000 births lower when the checklist was used.
- No overall mortality difference was found, but stillbirth reduction was significant during observed periods.

## Abstract

Is the World Health Organization (WHO) Safe Childbirth Checklist associated with evidence-based practices (EBPs) and mortality?

In this meta-analysis, encompassing more than 6000 standardized observations and health data from birth registries on more than 160 000 mother-newborn pairs across India, Indonesia, and Pakistan, adherence to EBPs increased by 24 percentage points with the use of the WHO Safe Childbirth Checklist. Although no difference in mortality was detected in the full sample, stillbirth rates were 9.76 per 1000 births lower when checklist use was observed.

The WHO Safe Childbirth Checklist was associated with increased application of EBPs and lower stillbirth rates when implemented in settings that enable compliance with the checklist.

This meta-analysis uses data from cluster randomized trials in India, Indonesia, and Pakistan to examine the outcomes of the implementation of the World Health Organization Safe Childbirth Checklist.

The World Health Organization (WHO) Safe Childbirth Checklist (SCC) has been adapted and implemented in at least 35 countries. Consistently, the SCC has shown increased adherence to practices, but there are mixed results regarding its association with health outcomes in different settings.

To examine the association of SCC implementation with mortality, accounting for variations in evidence-based practices (EBP) adherence.

In this meta-analysis, data were pooled from 3 cluster randomized trials of the SCC (January 1, 2014, to December 31, 2017). Intention to treat (ITT) and a complier average causal effect analysis (CACE) on EBPs and perinatal mortality were estimated via a generalized linear model. The primary facilities were in Uttar Pradesh, India; basic emergency obstetric facilities were in Aceh, Indonesia; and primary and secondary health centers were in Khyber Pakhtunkhwa, Pakistan.

In India, the 8-month SCC intervention involved facility engagement, a launch event, and 8 months of tapered coaching. In Indonesia, the 6-month SCC intervention included 11 coaching visits. In Pakistan, the 12-month SCC intervention included light touch external monitoring, skills training, and supplies assessment.

Primary outcomes were stillbirth and perinatal and early neonatal mortality. Secondary outcomes were adherence to 15 EBPs, facility supply availability, and safety culture perceptions.

Pooled data included 169 511 births, supply assessments from 163 facilities, and 6298 observed deliveries for EBPs and health workers’ perceptions on safety culture. Mortality did not differ in the full sample; however, during months when EBP observations were conducted, stillbirth rates in the intervention facilities were lower by 9.8 per 1000 births (95% CI, −18.5 to −1.1; P = .03; q = .05) in the ITT analysis and 14.5 per 1000 births (95% CI, −27.2 to −1.7; P = .03; q = .05) in the CACE analysis compared with control facilities. EBP adherence was higher by 3.6 practices (95% CI, 3.3 to 4.1; P < .001; q = .001) in the ITT analysis and 6.0 practices (95% CI, 5.3 to 6.8; P < .001; q = .001) in the CACE analysis in intervention facilities.

In this meta-analysis, SCC use in lower-middle-income settings was associated with increased EBP adherence and lower rates of stillbirths when EBPs were directly observed. Further research is needed to identify additional factors to optimize SCC’s potential impact on maternal and newborn safety outcomes.