Maternal Mortality Rate (MMR) in Cameroon has increased considerably between 1990 and 2014, from 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 limitations since 2010—2011 as it doesn’t integrate early post-partum follow-up. It also doesn’t indicate thresholds for some materno-fetal comorbidities like duration of premature rupture of membranes and preeclampsia. The WHO advocates the use of safe delivery checklist 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 birth outcomes.
We found that introducing the WHO SCC using the engage-launch-support strategy was a rewarding task. The improved adherence to essential birth practices (EBP) is attributed to the use of the checklist as it was the new strategy implemented in the unit. The engage phase involved the education of service providers on the checklist during a staff meeting, provision of copies of the checklist alongside instructions to get it incorporated 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 labor did not occur after at most 6 hours was rapidly identified using the checklist and managed as indicated. The assessment of other materno-fetal 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 computerization of medical records, which the hospital is currently implementing, may solve this problem of missing indicators.
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 not using 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 many 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 at 2.2% in Low Middle Income Countries (LMICs), the WHO Multicountry Survey. On the other hand, the prevalence of preeclampsia found in our study was relatively low, when compared to 8% and 12% reported in three referral hospitals in Cameroon in 2014 [12]. Further, the heterogeneous nature of preeclampsia makes it unlikely that a single risk factor can predict women who will develop it at birth or in post-partum [13]. The small proportion of patients with preeclampsia within the group where checklists were used may be the result of prompt intervention following increased routine blood pressure (BP) checks as prescribed. 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 emergency situations 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, the use of the checklist saw a decline in the proportion of obstetrical and neonatal complications. Checklists were incorporated into patient files. The percentage of 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.
The most obvious consequence of the convenience sampling method used is sampling bias. As a result, our sample is not representative of the general population of women who gave birth at our facility. The minimum sample size was attained; therefore the results are sufficiently powered to detect precise associations and differences between the groups studied. Since, the main aim of this study was to compare outcomes in cases where the checklist was used and not used; the sampling bias doesn’t affect the quality of our results and conclusions [1].
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.