Does adherence to evidence-based practices during childbirth prevent perinatal mortality? A post-hoc analysis of 3,274 births in Uttar Pradesh, India

Katherine Ea Semrau, Kate A Miller, Stuart Lipsitz, Jennifer Fisher-Bowman, Ami Karlage, Bridget A Neville, Margaret Krasne, Jonathon Gass, Amanda Jurczak, Vinay Pratap Singh, Shambhavi Singh, Megan Marx Delaney, Lisa R Hirschhorn, Bhalachandra Kodkany, Vishwajeet Kumar, Atul A Gawande, Katherine Ea Semrau, Kate A Miller, Stuart Lipsitz, Jennifer Fisher-Bowman, Ami Karlage, Bridget A Neville, Margaret Krasne, Jonathon Gass, Amanda Jurczak, Vinay Pratap Singh, Shambhavi Singh, Megan Marx Delaney, Lisa R Hirschhorn, Bhalachandra Kodkany, Vishwajeet Kumar, Atul A Gawande

Abstract

Background: Evidence-based practices that reduce childbirth-related morbidity and mortality are core processes to quality of care. In the BetterBirth trial, a matched-pair, cluster-randomised controlled trial of a coaching-based implementation of the WHO Safe Childbirth Checklist (SCC) in Uttar Pradesh, India, we observed a significant increase in adherence to practices, but no reduction in perinatal mortality.

Methods: Within the BetterBirth trial, we observed birth attendants in a subset of study sites providing care to labouring women to assess the adherence to individual and groups of practices. We observed care from admission to the facility until 1 hour post partum. We followed observed women/newborns for 7-day perinatal health outcomes. Using this observational data, we conducted a post-hoc, exploratory analysis to understand the relationship of birth attendants' practice adherence to perinatal mortality.

Findings: Across 30 primary health facilities, we observed 3274 deliveries and obtained 7-day health outcomes. Adherence to individual practices, containing supply preparation and direct provider care, varied widely (0·51 to 99·78%). We recorded 166 perinatal deaths (50·71 per 1000 births), including 56 (17·1 per 1000) stillbirths. Each additional practice performed was significantly associated with reduced odds of perinatal (OR: 0·82, 95% CI: 0·72, 0·93) and early neonatal mortality (OR: 0·78, 95% CI: 0·71, 0·85). Each additional practice as part of direct provider care was associated strongly with reduced odds of perinatal (OR: 0·73, 95% CI: 0·62, 0·86) and early neonatal mortality (OR: 0·67, 95% CI: 0·56, 0·80). No individual practice or single supply preparation was associated with perinatal mortality.

Interpretation: Adherence to practices on the WHO SCC is associated with reduced mortality, indicating that adherence is a valid indicator of higher quality of care. However, the causal relationships between practices and outcomes are complex.

Funding: Bill & Melinda Gates Foundation.

Trial registration details: ClinicalTrials.gov: NCT02148952; Universal Trial Number: U1111-1131-5647.

Keywords: maternal health; obstetrics; public health.

Conflict of interest statement

Competing interests: AAG receives royalties for books and essays, including on improving quality and delivery of healthcare using checklists. AAG is also the Chairman fo the Board of Haven, the health care venture formed by Amazon, Berkshire Hathaway, and JPMorgan Chase.

© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY. Published by BMJ.

Figures

Figure 1
Figure 1
Cumulative adherence to practice and perinatal mortality.

References

    1. Wang H, Bhutta ZA, Coates MM, et al. . Global, regional, national, and selected subnational levels of stillbirths, neonatal, infant, and under-5 mortality, 1980-2015: a systematic analysis for the global burden of disease study 2015. Lancet 2016;388:1725–74. 10.1016/S0140-6736(16)31575-6
    1. Montagu D, Sudhinaraset M, Diamond-Smith N, et al. . Where women go to deliver: understanding the changing landscape of childbirth in Africa and Asia. Health Policy Plan 2017;32:1146–52. 10.1093/heapol/czx060
    1. Randive B, Diwan V, De Costa A. India's conditional cash transfer programme (the JSY) to promote institutional birth: is there an association between institutional birth proportion and maternal mortality? PLoS One 2013;8:e67452. 10.1371/journal.pone.0067452
    1. Ng M, Misra A, Diwan V, et al. . An assessment of the impact of the JSY cash transfer program on maternal mortality reduction in Madhya Pradesh, India. Glob Health Action 2014;7:24939. 10.3402/gha.v7.24939
    1. Fink G, Ross R, Hill K. Institutional deliveries weakly associated with improved neonatal survival in developing countries: evidence from 192 demographic and health surveys. Int J Epidemiol 2015;44:1879–88. 10.1093/ije/dyv115
    1. van den Broek NR, Graham WJ. Quality of care for maternal and newborn health: the neglected agenda. BJOG 2009;116:18–21. 10.1111/j.1471-0528.2009.02333.x
    1. Raven JH, Tolhurst RJ, Tang S, et al. . What is quality in maternal and neonatal health care? Midwifery 2012;28:e676–83. 10.1016/j.midw.2011.09.003
    1. Hulton LA, Matthews Z, Stones RW. Applying a framework for assessing the quality of maternal health services in urban India. Soc Sci Med 2007;64:2083–95. 10.1016/j.socscimed.2007.01.019
    1. World Health Organization Standards for improving quality of maternal and newborn care in health facilities. Geneva: World Health Organization, 2016.
    1. The Safe Childbirth Checklist Program Background Paper International consultation meeting. WHO Headquarters, Geneva, Switzerland: World Health Organization, 2009.
    1. Bhutta ZA, Das JK, Bahl R, et al. . Can available interventions end preventable deaths in mothers, newborn babies, and stillbirths, and at what cost? Lancet 2014;384:347–70. 10.1016/S0140-6736(14)60792-3
    1. Lee ACC, Cousens S, Wall SN, et al. . Neonatal resuscitation and immediate newborn assessment and stimulation for the prevention of neonatal deaths: a systematic review, meta-analysis and Delphi estimation of mortality effect. BMC Public Health 2011;11:S12. 10.1186/1471-2458-11-S3-S12
    1. Haws RA, Thomas AL, Bhutta ZA, et al. . Impact of packaged interventions on neonatal health: a review of the evidence. Health Policy Plan 2007;22:193–215. 10.1093/heapol/czm009
    1. Opondo C, Allen E, Todd J, et al. . Association of the paediatric admission quality of care score with mortality in Kenyan hospitals: a validation study. Lancet Glob Health 2018;6:e203–10. 10.1016/S2214-109X(17)30484-9
    1. Spector JM, Lashoher A, Agrawal P, et al. . Designing the WHO safe childbirth checklist program to improve quality of care at childbirth. Int J Gynaecol Obstet 2013;122:164–8. 10.1016/j.ijgo.2013.03.022
    1. WHO WHO recommendations: intrapartum care for a positive childbirth experience. Geneva, 2018.
    1. Oladapo OT, Tunçalp Ö, Bonet M, et al. . WHO model of intrapartum care for a positive childbirth experience: transforming care of women and babies for improved health and wellbeing. BJOG 2018;125:918–22. 10.1111/1471-0528.15237
    1. Organization WH The safe childbirth checklist programme: an overview. Switzerland: World Health Organization, 2013.
    1. World Health Organization The Safe Childbirth Checklist Program: Background Paper [Internet]. Geneva, Switzerland: World Health Organization, 2009. Available: [Accessed cited 3 September 2020].
    1. Semrau KEA, Hirschhorn LR, Kodkany B, et al. . Effectiveness of the WHO safe childbirth checklist program in reducing severe maternal, fetal, and newborn harm in Uttar Pradesh, India: study protocol for a matched-pair, cluster-randomized controlled trial. Trials 2016;17:576. 10.1186/s13063-016-1673-x
    1. Kara N, Firestone R, Kalita T, et al. . The BetterBirth program: pursuing effective adoption and sustained use of the who safe childbirth checklist through Coaching-Based implementation in Uttar Pradesh, India. Glob Health Sci Pract 2017;5:232–43. 10.9745/GHSP-D-16-00411
    1. Semrau KEA, Hirschhorn LR, Marx Delaney M, et al. . Outcomes of a Coaching-Based who safe childbirth checklist program in India. N Engl J Med 2017;377:2313–24. 10.1056/NEJMoa1701075
    1. Marx Delaney M, Maji P, Kalita T, et al. . Improving adherence to essential birth practices using the who safe childbirth checklist with peer coaching: experience from 60 public health facilities in Uttar Pradesh, India. Glob Health Sci Pract 2017;5:217–31. 10.9745/GHSP-D-16-00410
    1. Office of the Registrar General & Census Commissioner Sample registration system statistical report 2014. New Delhi: Government of India, 2015.
    1. Division VS Annual health survey 2012-2013 fact sheet: Uttar Pradesh. New Delhi: Government of India, 2013.
    1. Molina RL, Neal BJ, Bobanski L, et al. . Nurses' and auxiliary nurse midwives' adherence to essential birth practices with peer coaching in Uttar Pradesh, India: a secondary analysis of the BetterBirth trial. Implement Sci 2020;15:1. 10.1186/s13012-019-0962-7
    1. Gass JD, Misra A, Yadav MNS, et al. . Implementation and results of an integrated data quality assurance protocol in a randomized controlled trial in Uttar Pradesh, India. Trials 2017;18:418. 10.1186/s13063-017-2159-1
    1. Gass JD, Semrau K, Sana F, et al. . Evaluation of a call center to assess post-discharge maternal and early neonatal outcomes of facility-based childbirth in Uttar Pradesh, India. PLoS One 2018;13:e0207987. 10.1371/journal.pone.0207987
    1. Hastie T, Tibshirani R. Generalized additive models. 1 edn New York: Chapman and Hall, 1990.
    1. Maisonneuve JJ, Semrau KEA, Maji P, et al. . Effectiveness of a WHO safe childbirth checklist Coaching-based intervention on the availability of essential birth supplies in Uttar Pradesh, India. Int J Qual Health Care 2018;30:769–77. 10.1093/intqhc/mzy086
    1. King HB, Battles J, Baker DP, et al. . TeamSTEPPS: Team Strategies and Tools to Enhance Performance and Patient Safety : Henriksen K, Battles JB, Keyes MA, et al., Advances in patient safety: new directions and alternative approaches (vol 3: performance and tools). Rockville (MD), 2008.
    1. Kumar S, Yadav V, Balasubramaniam S, et al. . Effectiveness of the who SCC on improving adherence to essential practices during childbirth, in resource constrained settings. BMC Pregnancy Childbirth 2016;16:345. 10.1186/s12884-016-1139-x
    1. Marx Delaney M, Miller KA, Bobanski L, et al. . Unpacking the null: a post-hoc analysis of a cluster-randomised controlled trial of the who safe childbirth checklist in Uttar Pradesh, India (BetterBirth). Lancet Glob Health 2019;7:e1088–96. 10.1016/S2214-109X(19)30261-X
    1. Rowe AK, de Savigny D, Lanata CF, et al. . How can we achieve and maintain high-quality performance of health workers in low-resource settings? Lancet 2005;366:1026–35. 10.1016/S0140-6736(05)67028-6
    1. Michie S, van Stralen MM, West R. The behaviour change wheel: a new method for characterising and designing behaviour change interventions. Implement Sci 2011;6:42. 10.1186/1748-5908-6-42
    1. Pronovost PJ, Berenholtz SM, Goeschel CA, et al. . Creating high reliability in health care organizations. Health Serv Res 2006;41:1599–617. 10.1111/j.1475-6773.2006.00567.x
    1. Pronovost PJ, Berenholtz SM, Needham DM. Translating evidence into practice: a model for large scale knowledge translation. BMJ 2008;337:a1714. 10.1136/bmj.a1714
    1. Kerber KJ, de Graft-Johnson JE, Bhutta ZA, et al. . Continuum of care for maternal, newborn, and child health: from slogan to service delivery. Lancet 2007;370:1358–69. 10.1016/S0140-6736(07)61578-5
    1. Tunçalp Ӧ, Were WM, MacLennan C, et al. . Quality of care for pregnant women and newborns-the who vision. BJOG 2015;122:1045–9. 10.1111/1471-0528.13451
    1. Deeny SR, Steventon A. Making sense of the shadows: priorities for creating a learning healthcare system based on routinely collected data. BMJ Qual Saf 2015;24:505–15. 10.1136/bmjqs-2015-004278
    1. McCambridge J, Witton J, Elbourne DR. Systematic review of the Hawthorne effect: new concepts are needed to study research participation effects. J Clin Epidemiol 2014;67:267–77. 10.1016/j.jclinepi.2013.08.015

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