Maternal Mortality Rate (MMR) in Cameroon has increased considerably between 1990 and 2014, with 430 – 782 deaths per 100 000 live births, which is unacceptable. These deaths pushed the health sector to generalize the use of the partograph during childbirth, as a quality indicator and a tool to reduce maternal mortality. However, this practice has had limitations since 2010 – 2011 as it doesn’t integrate early post-partum follow-up and it does not indicate thresholds for some risk factors of materno-foetal morbidities like premature rupture of membranes and preeclampsia. The World Health Organization (WHO) advocates the use of safe delivery checklists as it integrates other variables to improve the standard of care for women and babies at the time of childbirth. No study was found on this in Cameroon. As a hospital whose primary mission is to provide quality maternal and child care, we saw the WHO SCC as a gold mine to explore. Therefore, we instituted the WHO SCC and studied the relationship between its use and materno-foetal outcomes.
We found that introducing the WHO SCC using the engage-launch-support strategy was a rewarding task. The improved adherence to EBP is attributed to the use of the checklist as that was the new strategy implemented in the unit. The engage phase involved the education of service providers on the checklist during a regular staff meeting, providing them with copies of the checklist and instructing them to incorporate it in their routine practice. Members of the department imbibed and incorporated the checklist into their routine practice as reported in the results section. Very few adaptations were made to the checklist to suit our local context at this time. After concertation, the duration of premature rupture of membranes which is one of the conditions to start maternal antibiotics was modified from greater than 18 hours to 6 hours on page 1 of the checklist. Although no formal practical training sessions were organized, the health care providers learned by applying what they were taught on the job and supporting each other Consequently, every woman with premature rupture of membranes in whom spontaneous labour did not occur after at most 6 hours was rapidly identified using the checklist and managed as indicated. The assessment of other materno-foetal outcomes such as bacterial vaginitis, early neonatal sepsis and their association with the use of the checklist was not done because this information was not available in all medical records.
The official launching of the WHO SCC was done at a seminar organized in the month of March 2018. Implementation outcomes included the level of knowledge, the usage rate of the WHO SCC and the health of mothers and newborns. The overall adoption rate was (828/976 files; 84.8%). This is about double the rate recorded in a tertiary care setting in Sri Lanka during a prospective observational study, but similar to findings in Namibia, a Sub Saharan African country [9,10]. The pages with the following childbirth practices were checked least often: confirming if mother needed to start antibiotics or antihypertensive treatment during labor or after delivery, seeking an assistant during labor, checking the availability of mother and baby’s essential delivery supplies, abnormal bleeding control after birth, early breastfeeding, baby’s referral, special care, monitoring and the newborn’s need for antibiotics.
Four out of eight service providers complained that the checklist increased their workload while 2/8 cited the non-availability of checklists in patient files as the reason for non-use of the checklist. The former reflects a problem with either their attitude or the level of knowledge on the checklist while the latter could be handled by systematically pinning a checklist to every nursing file. The inclusion of the use of the checklist in their work package without any practical training for easy use tips could also be the reason. This explains the suboptimal utilization of the checklist. These findings are different from those reported by Perry et al. who reported that end users of the checklist in a global collaboration were extremely willing to use the checklist when first introduced [11]. Most service providers (5/8) defined the WHO SCC as “a control, monitoring and recall tool which serves as a reminder for actions to take at each step of patient care”. The challenge therefore is to work on attitudes of providers and to improve the practice of Childbirth checklists through refresher training sessions and supportive supervision.
The estimated occurrence of preeclampsia and eclampsia was less than 3% in our study and a higher number of cases were associated with the non-use of the WHO SCC. This is similar to the findings reported by the largest hospital-based cohort on the prevalence of pre-eclampsia in Low Middle Income Countries (LMICs), the WHO Multicountry Survey reported an overall prevalence of 2.2%. On the other hand, the prevalence of preeclampsia found in our study was relatively low, when compared to that found in 2014, in three referral hospitals in Cameroon which was between 8 and 12% [12]. Furthermore, although the heterogeneous nature of preeclampsia makes it unlikely that a single risk factor can predict women likely to develop it at birth or in post-partum [13], the reduced proportions of patients with preeclampsia seen in the records of those for who the safe childbirth checklist may be the result of prompt intervention following increased routine BP checks associated with the use of the checklist. Published reports show that patients with obstetric complications such as eclampsia/preeclampsia frequently undergo cesarean sections especially as emergencies [14]. Therefore, the short reaction time available in emergencies could explain the non-use of the checklist. However, during our qualitative analysis, none of the staff reported emergencies as one of the reasons for not using the checklist. And emergencies should not deter the healthcare provider from providing essential birth practices as that is what will save the patient.
Over time, with the implementation of the use of the checklist with parturients, a decline in obstetrical and neonatal complications was noticed( Table …) as the rates of neonatal complications dropped during the 6 months of the intervention. Checklists were incorporated into patient files. Obstetrical complications rose during the first four months from 7.2% to 20.7% and then dropped to 6.9% during the last two months amongst cases with filled checklists. Poor utilization and completion of the checklist during the first 2 months may have contributed this. We strongly believe that the use of the safe childbirth checklist enhanced adherence to essential birth practices and thus during the post intervention audit, more complications were noticed when the checklist was not in use.
Study limitations
This is a retrospective study. we had no influence on the quality of data entered into the delivery records. However; measure taken to minimize this limitation was comparison with data in delivery registers and service reports. The study was only carried out in one facility because it was a pilot research work. From the positive results obtained and presented to the personnel, we intend to get other health facilities to implement this recall tool. The fact that logistic regression was not carried out is a limitation that prevents the prediction of the nature of the association between outcome and checklist use or non use.