Checklist Conquers Childbirth Casualties

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UTTAR PRADESH, India – India boasts many overwhelming statistics ranging from its population of almost 1.25 billion and its industrial power to its extensive historical significance; however, another notable stride is currently being made in childbirth and infant mortality rates.  In the northern state of Uttar Pradesh, a pilot collaboration between the World Health Organization (WHO,) the Bill and Melinda Gates Foundation, Population Services International and a skilled collection of Boston, Massachusetts professionals are changing infant mortality rates with a simple checklist.

The concept began in 2001 with Peter Pronovost, a critical-care specialist at Johns Hopkins Hospital and a research study. Pronovost created a checklist of the necessary steps to prevent IV line infections, starting with using soap to wash hands. The results were profound: during the year-long study only two infections occurred, saving $2 million, eight lives, and preventing 43 infections. Provonost’s success caught the attention of Atul Gawande, a surgeon, researcher, author and associate Harvard professor based in Boston. Gawande developed the Safe Surgery Checklist, a similar collection of basic yet essential steps that reduced post-surgical deaths by 40 percent when implemented, which has been picked up by the WHO and distributed across the globe. Now, the world has a new checklist that is tackling one of the most problematic health issues: infant mortality.

While the study is being performed in Uttar Pradesh India, it is important to realize the checklist is not at all applicable exclusively to the health systems of developing countries. Pronovost’s groundbreaking study took place in Michigan, and the WHO has implemented Gawande’s Safe Surgery Checklist globally, including the United States. The team’s choice of Uttar Pradesh was deliberate.  The state is India’s most populace, with just shy of 200 million people, and has the highest fertility and infant mortality rates. Uttar Pradesh’s fertility rate is approximately 3.4 births and its infant mortality rate is 57 per 1,000 live births, both of which mirror the statistics in Haiti. If a change could be made in Uttar Pradesh, it would be proof that the system was successful.

Of 120 facilities in the study, half are instructed in how to use the Safe Childbirth Checklist. Professionals from Harvard are developing the training with Population Services International (PSI) on how to introduce and assist nurses and doctors in health care facilities utilizing the list.  PSI nurse-coaches in turn teach and directly train local nurses in the concepts. Once again, the checklist identifies basic steps not new skills. The 29-items are divided into four stages: admission, just before pushing (or before Caesarean,) soon after birth (within 1 hour,) and before discharge. Questions include, “Does Mother need referral?”, “Does Mother need to start antibiotics?”, “Is Mother bleeding abnormally?” and “Is Baby feeding well?”. If needed, further instructions are next to each question.

Robyn Churchill is a member of the small Harvard training team that has joined forces with the Brigham and Women’s Hospital to create a center for health systems innovation called Ariadne Labs. One obstacle is merely convincing individuals that the checklist is beneficial. Whether in India or in Boston, both the childbirth and surgical checklists have sometimes been met with skepticism by professionals who assure the team that their personal methods are much better than the checklist. Some feel the perceived nuisance of filling out a checklist is not worth the time when their particular methods have served them so well throughout their career. The Harvard and Indian teams are careful not to dictate the checklist’s terms, but rather to use person-to-person communication to collaborate with local professionals.

Logistics are another obstacle. Like many places, Uttar Pradesh has a shortage of healthcare facilities and professionals. The state is short 2,258 primary and community health centers as required by India’s National Rural Health Mission. In addition, there is a shortage of 4,670 nurses. All in all, there are 36,289 females per nurse. Churchill, a midwife, estimates over 10 years, she delivered approximately 1,000 babies, while her average counterpart in Uttar Pradesh delivers the same amount in a single year since almost 50 percent of nursing positions are unfilled.

While acknowledging the staff is exceedingly busy, the team works to make the checklist a matter of personal achievement or pride rather than yet another chore. One woman even crossed caste barriers to get staff involved in improving standards and care, which Churchill cites as exactly the type of quality initiative the team aims to incite. Other logistical problems have easy solutions once identified, such as the older nurse who repeatedly did not comply with taking mothers and infants’ temperatures because she did not have glasses and could not read the results. The local team member quickly solved the problem by providing a different type of thermometer.

Through her periodic visits, Churchill has noted impressive changes. Beyond statistical improvements, the study is sparking innovation and problem solving in those involved. However, the concept of coaching is not typically part of global healthcare, whether in Boston or in Uttar Pradesh. Despite overwhelming support for the steps on the checklist (no one denies washing hands is a good thing), the actual implementation of such steps requires careful attention and dedication. Churchill and the larger team of supporters, researchers and experts believe this study in Utter Pradesh could have a massive impact.  They estimate that if infant mortality in Uttar Pradesh can be reduced 20 percent it would reduce global rates by over one percent. The highly anticipated results are currently scheduled to conclude in 2016.

– Katey Baker-Smith

Sources: 2011 Census, The New Yorker, The World Health Organization, The World Bank, National Health Mission, UN Population Reference Bureau, Government of Uttar Pradesh
Photo: Save The Children

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