How A Checklist Can Help Address Causes of Mother, Infant Death in Childbirth

After years of testing in dozens of countries around the world, the Safe Childbirth Checklist was recently released by the World Health Organization (WHO) in collaboration with Ariadne Labs, a joint center of Brigham and Women’s Hospital and the Harvard T.H. Chan School of Public Health. Scientists at Ariadne Labs helped develop and adapt the checklist and, with Population Services International, are leading the largest randomized controlled trial – called the BetterBirth Program –to test its effectiveness at lowering maternal and neonatal deaths. The BetterBirth Program is implementing the checklist with peer-to-peer coaching and data feedback in more than 100,000 live births across Uttar Pradesh, India.

In this Q&A,  Dr. Katherine Semrau, a Brigham epidemiologist in the Division of Global Health Equity and the Director of the Ariadne Labs BetterBirth Program, tells us more about the Safe Childbirth Checklist.

Katherine Semrau, PhD, MPH
Katherine Semrau, PhD, MPH

How are we doing, globally speaking, when it comes to maternal and neonatal care in childbirth?

Since the establishment of the Millennium Development Goals in 2000, we have made great strides globally in reducing maternal mortality by 43 percent. Unfortunately, reductions in newborn mortality have been marginal; 45 percent of all child mortality occurs in the first 28 days of life. Even with these successes, 303,000 women and 2.9 million newborns die each year. We can do better.

Much of the focus on reducing maternal and newborn mortality has been on improving access to facility-based delivery with a skilled birth attendant in low- and middle-income countries. This approach has improved access to care—but that alone has not solved the problem.

There are so many interventions out there for maternal and neonatal health. Why is the checklist the right approach for right now?

We know why women and infants die in childbirth. And most of the causes are preventable. But around the world there are huge gaps between knowledge and practice when it comes to childbirth. The WHO Safe Childbirth Checklist is a tool that unifies the most basic and minimum care standards that every woman should receive when giving birth in a clinical setting. The checklist helps birth attendants to prioritize easy-to-perform inexpensive behaviors around the delivery process that make childbirth safer for women and infants – steps like hand washing, giving antibiotics, checking for bleeding and ensuring mothers and infants have skin-to-skin contact after delivery.

As simple as they sound, these checklist items address the major reasons why complications and deaths occur in childbirth: hemorrhage, infection, hypertensive disorders and birth asphyxia.

In India, we’ve seen another positive benefit of using the checklist. It becomes a rallying point for stakeholders at all levels to improve care for women and babies. Birth attendants and health facility administrators can use their experience with the checklist to advocate for more training, human resources and supplies.

A lot of work has gone into the release of the WHO Safe Childbirth Checklist. Can you talk a bit about the testing that has gone into the checklist we see being launched now?

The checklist was developed through the cooperation of health experts around the world and has been tested in 29 countries across 234 sites. The checklist and accompanying Implementation Guide incorporate feedback from partners across more than 20 countries. BetterBirth, the randomized control trial we’re conducting in Uttar Pradesh, India, with Population Services International, is the largest trial testing the checklist to assess impact on uptake of essential birth practices and maternal morbidity and mortality, stillbirth and early neonatal mortality. Our approach in BetterBirth has been to couple the checklist with peer-to-peer coaching of birth attendants and real-time data feedback that enables health facilities to make immediate changes to improve the quality of care.

How do you achieve buy-in for a checklist, especially if you are trying to implement it in so many different settings around the world?

Getting buy-in isn’t always easy. Our experience with the Safe Childbirth and Safe Surgery Checklists is that making a tool a requirement, without implementation support, doesn’t work.

We have to demonstrate the value of the checklist and make sure it is adapted in a way that makes sense to the local setting. We’ve developed some novel approaches to achieving buy-in. For instance, in India we created three culturally appropriate videos that support the launch of the checklist.

What can people do if they are interested in using the checklist and learning more about the work that Ariadne Labs is doing?

We are very interested in taking the next steps toward scaling the Safe Childbirth Checklist to more settings around the world. We work with the WHO and implementers to support checklist use by adapting materials and trainings to local contexts; adapting orientation and training materials to launch the checklist in these contexts; supporting coaching efforts; developing monitoring and evaluation tools and even adapting our data capture and report feedback system.

A great first step is to check out the new Implementation Guide. Clinicians can also join our online Community of Practice and email us at for more information.