Over the last three years, the BetterBirth Program team at Ariadne Labs partnered with Population Services International, Community Empowerment Lab, Jawaharlal Nehru Medical College, the World Health Organization(WHO) and the Government of India, to lead one of the world’s largest maternal newborn health trials in the Indian state of Uttar Pradesh. The goal of the trial was to test an intervention to reduce deaths by improving the quality of care in frontline facilities. These frontline facilities had on average 1,200 deliveries per year, or 3-4 per day; most deliveries were conducted by nurses. Before the intervention started, less than 1% of staff washed their hands prior to delivery. Only 25% of women received the right medications to prevent postpartum bleeding. Overall adherence to standard practices was 40%.

Using bedside peer-coaching of birth attendants and facility managers, along with the WHO Safe Childbirth Checklist, we focused on improving birth attendants’ use of basic care practices such as hand washing to prevent infection, monitoring and treatment of women’s blood pressure to prevent eclampsia and appropriate medication to prevent hemorrhage.

The results showed marked improvement in care. Birth attendants completed 70% of the known life-saving steps during childbirth after receiving coaching and the Checklist. Yet it was not enough. We saw no reduction in mortality rates.

These findings may be surprising to some, as they were to me initially. However, digging into the data with a sharp focus on understanding why there was no change in mortality rates has revealed insights for advancing maternal and newborn health. After all, we are all pushing to make maternal and newborn health better, safer and of high quality.

Here are 10 key learnings that have emerged so far:

1. Improving the quality of facility-based care provided to women during labor and delivery is a critical component of achieving reductions in maternal/perinatal mortality. More than 70% of women globally deliver in a health facility, and the highest risk period for women and their newborns is the 48 hours around birth. To improve outcomes, our attention must shift beyond access and coverage to the quality of the care being provided in facilities.

2. Significant improvement in quality of facility-based care is possible in low-resource settings. Measures like skills building trainings, supportive supervision and supplies and equipment provision can make a difference to the quantity of services provided, the technical quality delivered and the delivery of care. The remaining questions focus on sustainability of those changes and maintenance of health systems to support quality improvement (QI).

3. Coaching birth attendants to use the Safe Childbirth Checklist is an effective strategy to improve the quality of childbirth care being delivered at the health facilities. The methods tested in the BetterBirth trial focused on using coaching along with the WHO Safe Childbirth Checklist. Use of the Checklist is not about simply ticking a box—rather it employs the tool as a reminder or guide for following basic practices. Birth attendants found the Checklist to be helpful as an organizing tool for ensuring adequate supplies and for critical steps when a woman’s blood pressure or temperature is elevated. The coaching model, tested in the pilot phase of the trial, was most successful with a peer-to-peer coaching rather than supervisor to birth attendant or doctor to nurse.

4. More is required to reduce maternal and perinatal mortality. In the trial, there was no difference in mortality between intervention sites and control sites, despite observed behavior change. This tells us that other parts of the health system failed to close the gaps on complication management, supply availability, staff skills, etc.

5. Health workforce skill level, supply chain, referrals, transportation and leadership need to be addressed for successful quality improvement. Our data show the health system and its interconnectedness (or lack thereof) strongly affected the mortality rates, and that the combination of the Checklist along with peer coaching did not overcome limitations. Assessment of some of these factors is relatively straightforward (i.e. supply availability), but other areas like leadership and skills levels require further investigation for the best assessment techniques. Observation of all deliveries by independent data collectors is not feasible; as a community, we need to find novel methods of measurement.

6. Ending the preventable deaths of mothers and newborns will require greater investment in quality across the continuum of care, from the antenatal to postnatal periods and beyond. In our experience and setting, women arrived at the facility advanced in labor, which provided limited time for a birth attendant—no matter how trained or skilled—to respond to emergencies/complications or refer to a higher-level facility, if required. Further, women left the facility shortly after delivery; many left well before the minimum 24-hour recovery period. Strategies that improve antenatal and postnatal care and service uptake are essential to impacting health outcomes for women and newborns. Facilities need to provide person-centered, respectful care throughout pregnancy, delivery and during the postpartum period and community members need to know their rights and demand high quality care.

7. The improvements needed to achieve maternal mortality outcomes will require timely interfacility referrals and communication. Among the 149 women who died during the study, we observed that many women were referred to higher-level facilities but often faced difficulties obtaining adequate care. Connections between the health facility and hospitals were limited with inadequate information being given to families or the referral facility as to the complication, management, etc. Referring facilities must be able to stabilize women and refer them appropriately. Referral facilities must be aware that a woman is incoming and the transportation system has to provide adequate support.

8. There is a need to develop facility-level, regional and national criteria for readiness to implement checklist-based quality improvement programs for childbirth. While there are needs assessment tools used in the global maternal newborn health field, there is no tool that can predict a facility’s ability to take on a QI program. Finding ways to better assess the capability of a facility in the QI space is critical to success. We can use this improved assessment information to either address the gaps or adapt implementation strategies so sites are more likely to be successful.

9. Data-driven tools are needed to measure, track and assess system readiness over time. Building on the concept of readiness and capability, data-driven, simple tools are required to accurately track facility progress over time. It is essential that these tools incorporate and integrate with existing data systems. There are sufficient indicators for maternal and newborn health; what we need are methods and systems to utilize this data more efficiently and effectively.

10. There is a need to develop systems-level interventions that facilitate capacity building for health systems that want to implement the Safe Childbirth Checklist to improve outcomes for women and babies. Ariadne Labs has been supporting the uptake of the WHO Safe Childbirth Checklist in a variety of contexts and settings in 30 countries. Systems-level approaches are required to make QI programs a success. We need to learn from the sites their strategies for success and methods for removing barriers.

Lessons learned from the project were presented during a webinar on 25 April 2018, if you missed it you can watch the recording and download the slides.