This study assessed the use of the SCC at the YGOPH and its association with obstetric and neonatal complications during the six-month period following the SCC implementation. The mean age of our study population was 28 ± 6 years. Of the 976 delivery records, 828 used the checklists. Severe pre-eclampsia/eclampsia were associated with the non-use of SCC (2.1% Vs 5.4%, p = 0.017).
In this study, the mean adoption rate of the SCC over a six-month period was 84.8% (828/976 files). This value is twice as high as the adoption rate (45.8%) reported in a tertiary care setting in Sri Lanka during a two-month prospective observational study, conducted in 2013 [24]. According to table 2, there are approximately 370 deliveries conducted in two months by a staff of 20, meanwhile at De Soysa Women's Hospital (DSWH), in Sri Lanka, the ratio of births to the number of workers is significantly higher. Therefore, the greater workload and short duration of study at the DSWH could have contributed to this difference in adoption rates. Additionally, a deeper commitment to quality improvement by the staff of YGOPH may explain the higher adoption rate such that by June, almost all deliveries (93.9%) were managed with a filled childbirth checklist. Another study conducted in a district hospital in Rwanda also found a high Essential Birth Practice (EBP) compliance at 56% over a two-month period following staff training on the SCC implementation [25].
Our evaluation found that the SCC-based intervention at the YGOPH is associated with a significantly lower proportion (2·1% Vs 5·4%, p = 0·017) of severe pre-eclampsia/eclampsia cases. As concerns the mechanism by which this occurred, the SCC prompts the birth attendant to check the blood pressure on admission (See Table 1) and if indicated, commence prophylaxis with magnesium sulphate. This early blood pressure check ensures early identification and management, thus prevents deterioration to severe pre-eclampsia/eclampsia. This view is validated by the quasi-experimental study [26] done in Rajasthan, India, which observed a positive behavioural change in health care providers associated with the implementation of the SCC. The greatest difference (64%) was reported in early identification, management and timely referral of cases of pre-eclampsia [26]. Though, the Better-Birth study, a cluster-randomized, controlled trial in Uttar Pradesh, India, found no significant impact of the SCC intervention on maternal morbidity or mortality [27], unavailability of medications and consumables may have been responsible. Although both studies are based on the SCC, they differ in context. The Better-Birth study facilities were a combination of primary health care facilities and community health centres, whereas YGOPH is a tertiary-level facility. We posit that in the context of adequate human and material resources, the use of the SCC will be associated with a significant reduction on maternal morbidity and mortality.
After multivariate analysis, the significant variation in the proportion of severe pre-eclampsia and eclampsia cases in both SCC groups is maintained when the results are adjusted for differences in age, parity and history of hypertension. (See Table 5)
Figure 1 shows a progressive decline in the proportion of maternal complications with the use of the SCC over time. Checklists were attached to clinical notes. The percentage of adverse maternal outcomes dropped to 6.9% during the last two months amongst cases with filled checklist. As described in previous studies, the use of the SCC with regular coaching or supervision improves adherence to essential birth practices, thereby resulting in fewer complications when providers have adequate skills alongside the availability of supplies [21,22].
Stillbirth, neonatal asphyxia and neonatal death rates were not statistically different between checklist and non-checklist groups, as shown in figure 2. However, in all neonatal outcomes, the proportion of complications was less when the checklist was used. Thus, we agree with other published works that non-adherence to the essential birth practices affect the quality of care and consequently neonatal outcomes [16, 28, 29].
Study limitations
This study is a review of outcomes during the implementation research in one facility to provide better quality of care during childbirth. 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.
Out of 1611 deliveries conducted during the study period, 1001 delivery records were found, giving a retrieval rate of 62%. We currently have a paper-based archiving system, and one of the limitations associated with this is the loss of files in the patient record circuit. However, the hospital is in the process of computerizing her medical records, to eradicate the problem of missing records.
Conclusion and recommendations
The use (adoption rate) of the SCC increased to 93.9% of all deliveries within six months of implementation. Our study showed that the utilization of the SCC was associated with a significant reduction in the onset of severe pre-eclampsia/eclampsia. We advocate for the use of the SCC in maternity units. From the positive results obtained, we intend to continue using this reminder tool and get other health facilities on board.
Perspectives
The hospital is transitioning to electronic medical records to enable better archival of her medical data.