Implementation of the WHO Safe Childbirth Checklist: a scoping review protocol

Abstract

Introduction

The WHO Safe Childbirth Checklist (WHO SCC) was developed to accelerate adoption of essential practices that prevent maternal and neonatal morbidity and mortality during childbirth. This study aims to summarise the current landscape of organisations and facilities that have implemented the WHO SCC and compare the published strategies used to implement the WHO SCC implementation in both successful and unsuccessful efforts.

Methods and analysis

This scoping review protocol follows the guidelines of the Joanna Briggs Institute. Data will be collected and reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews report. The search strategy will include publications from the databases Scopus, PubMed, Embase, CINAHL and Web of Science, in addition to a search in grey literature in The National Library of Australia’s Trobe, DART-Europe E-Theses Portal, Electronic Theses Online Service, Theses Canada, Google Scholar and Theses and dissertations from Latin America. Data extraction will include data on general information, study characteristics, organisations involved, sociodemographic context, implementation strategies, indicators of implementation process, frameworks used to design or evaluate the strategy, implementation outcomes and final considerations. Critical analysis of implementation strategies and outcomes will be performed with researchers with experience implementing the WHO SCC.

Ethics and dissemination

The study does not require an ethical review due to its design as a scoping review of the literature. The results will be submitted for publication to a scientific journal and all relevant data from this study will be made available in Dataverse.

Trial registration number

https://doi.org/10.17605/OSF.IO/RWY27.

STRENGTHS AND LIMITATIONS OF THIS STUDY.

• Our search strategy will include a broad range of databases and grey literature to obtain a comprehensive view of the organisations that implement the WHO Safe Childbirth Checklist (WHO SCC) globally.

• This exploratory approach aligns with recommendations to initiate and advance the dissemination and implementation process.

• The scoping review methodology will allow for synthesis of WHO SCC implementation strategies and their associated outcomes, which will be fundamental for guiding new implementation and re-implementation efforts by policymakers, managers and practitioners.

• This scoping review methodology was not designed to study the diverse contextual factors that influence the WHO SCC implementation or the dissemination efforts of the WHO SCC.

• Scoping reviews do not evaluate the quality of included primary studies or perform meta-analysis, therefore we are limited in generating conclusions about the quality of implementation research and effectiveness of implementation strategies.

Introduction

Maternal and neonatal death remains a global public health problem despite notable progress in recent years. Annually, there are approximately 287 000 maternal deaths,¹ 1.9 million intrapartum stillbirths and 2.3 million children die before 1 month of life.² These adverse outcomes occur primarily in low-income and middle-income countries^{1 2} and most of these deaths are avoidable. The United Nations Sustainable Development Goals includes targets for reducing the global maternal mortality rate to less than 70 deaths per 100 000 live births and reducing the neonatal mortality rate to at least 12 per 1000 live births by 2030.³

The WHO developed the Safe Childbirth Checklist (SCC) to address preventable causes of maternal and neonatal morbidity and mortality during facility-based childbirth.⁴ The SCC aggregates evidence-based guidelines recommended by the WHO, and contains 29 items that remind healthcare professionals to perform essential maternal and perinatal care practices at specific moments around the time of childbirth. The items are divided into four pause points—on admission, just before pushing or caesarean, within 1 hour after birth, and before discharge—and are focused on preventing the main causes of maternal death (bleeding, hypertensive diseases, infection), stillbirths and neonatal deaths (asphyxia, infection and prematurity). Further, the SCC can improve pregnant people’s birth experience by encouraging open communication before, during, and after childbirth.⁵

Growing evidence about the value of the WHO SCC has motivated many health systems and facilities to implement it,^{6 7} but questions remain about how to most effectively implement this tool. The WHO published an implementation guide in 2015 which accompanies the checklist,⁸ and there are numerous recommendations from implementers globally.^9–11 However, there has not been a comprehensive review of the use and effectiveness of varying implementation approaches and strategies.¹² Understanding the range and implementation outcomes of various implementation strategies worldwide could help improve its use and accelerate its potential effects on global targets for reducing maternal and neonatal deaths.

Therefore, this scoping review protocol aims (1) to describe the landscape of organisations and facilities that have implemented the WHO SCC; and (2) compare the published strategies used to implement the WHO SCC implementation in both successful and unsuccessful efforts. The results may help support policy makers, practitioners, quality improvement specialists and hospital leaders interested in implementing the SCC in their settings.

Materials and methods

This protocol follows the Joanna Briggs Institute manual for scoping reviews, based on the six steps suggested by Arksey and O’Malley¹³ and updated by Levac et al ¹⁴: (1) identification of the research question (inclusion and exclusion criteria); (2) identification of relevant studies; (3) selection of studies; (4) data extraction; (5) compilation, summary and reporting of results; and (6) synthesis of evidence. The findings will be organised and presented according to the PRISMA-ScR report (The Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews).¹⁵

Step 1: identification of the research question

To formulate the research question, we used the strategy Population, Concept and Context—PCC described in table 1 and the key concepts described in table 2.

Table 1.

Research questions and Population, Concept and Context strategy

Question	Population	Concept	Context
What organisations and facilities have implemented the WHO SCC?	Pregnant people and health personnel	Implementation of the Safe Childbirth Checklist (SCC)	Facility-based childbirth
What are the most effective implementation strategies for the WHO SCC?

Table 2.

Key concepts used in the study

PCC	MeSH	Key concept*
Population	Pregnant women/birthing people	Individuals who are pregnant, as cultural, psychological or sociological entities
	Health personnel	Individuals working in the delivery of childbirth care, whether as individual practitioners or employees of health institutions and programmes, regardless of professional training and public regulation
Concept	Checklist	Aid for consistent recording of data such as tasks completed and observations noted
	Implementation	The process of putting to use or integrating evidence-based interventions within a setting
Context	Parturition	The process of giving birth to one or more offspring, including labour, delivery and postpartum care
	Delivery, obstetric	Delivery of the fetus and placenta under the care of an obstetrician or a health worker. Obstetric deliveries may involve physical, psychological, medical or surgical interventions
	Labour, obstetric	The repetitive uterine contraction during childbirth which is associated with the progressive dilation of the uterine cervix. Successful labour results in the expulsion of the fetus and placenta. Obstetric labour can be spontaneous or induced

*The key concepts are based on Medical Subject Headings (MeSH), except for implementation that is based on the definition of National Institutes of Health.²² The term pregnant woman in this study represents any pregnant person, including those who identify across the gender spectrum.

Step 2: identification of relevant studies

The search will be conducted in the following databases: Scopus, PubMed, Embase, CINAHL and Web of Science. The review will also include grey literature identified from: Google Scholar, CAPES Theses and Dissertations Portal, The National Library of Australia’s Trobe, DART-Europe E-Theses Portal, Electronic Theses Online Service (EThOS), National ETD Portal, Theses Canada, Latin American Theses and Dissertations, and Global Health (C.A.B. International, EBSCOhost), Global Index Medicus (WHO, www.globalindexmedicus.net).

An initial, limited search was carried out on PubMed and Scopus to identify articles on the topic and generate the most applicable terms using the findings from this search and the concepts described in the PCC strategy. The descriptors were selected using the Health Sciences Descriptors (Decs) and Medical Subject Headings (MeSH). After initial results and discussion among our team of researchers with experience with WHO SCC, the following search strategy was established for PubMed:

((“childbirth checklist” OR “birth checklist” OR “labor checklist” OR “delivery checklist” OR “safe childbirth” OR Checklist”[Mesh]) AND (“Delivery, Obstetric”[Mesh] OR “Labor, Obstetric”[Mesh] OR “Parturition””[Mesh])) AND 2009[pdat]:2023[pdat].

We will carry out similar searches with the corresponding descriptors in the Scopus, Embase, CINAHL and Web of Science databases. The exact search in each database will be described in the scoping review.

The following search strategy was established for grey literature:

(“checklist” OR “check list”)) AND ((“childbirth” OR “birth” OR “delivery” OR “labor” OR “labour”).

For database in Portuguese (CAPES Theses and Dissertations Portal), the strategy was configured as follows:

(“lista de verificação” OR “checklist”) AND (“parto” OR “cuidado materno” OR “maternidade” OR “nascimento” OR “parturição”).

A preliminary search was carried out in the Scopus and PubMed databases in December 2023, without language restrictions and with publication date delimitation from 2009 (the year the WHO SCC began to be developed). After confirming the viability of the search strategy, the search was extended to the other databases. We also carried out a search in the grey literature (The National Library of Australia’s Trobe, DART-Europe E-Theses Portal, EThOS, Theses Canada, Google Scholar, Theses and dissertations from Latin America) using the search keyword “Safe Childbirth Checklist”.

Step 3: study selection

Any study that describes a strategy to implement the WHO SCC will be included in the review. Inclusion criteria are: full text available in any language; describes implementation of WHO SCC. Exclusion criteria are: any article published before 2009 (when the WHO SCC was developed); articles that describe other pregnancy-related checklists. Literature reviews, editorials, letters to the editor, and opinion articles will be excluded.

Two researchers will use Covidence systematic review software to complete the initial title and abstract screening and document reasons for exclusion.¹⁶ Duplicate articles will be removed. Two researchers will independently review the full text of included articles. Disagreements regarding inclusion will be resolved by a third reviewer. The results of the selection process will be presented in a PRISMA-ScR flowchart and include details of the research flow, selection of sources, duplicates, recovery of the full text, data extraction and presentation of evidence. Mendeley software will be used to organise the references.

Step 4: data extraction

A Google Form (see online supplemental appendix A) will be used to collect and organise the extracted data. The form will include: (1) general information (reviewer; date of data extraction; database; reference); (2) study identification (title; authors; year of publication; language; country; keywords; publication type); (3) study characteristics (objectives of the study; focus; design based on type of comparison¹⁷); (4) organisations involved (sites; funding; birth setting; public setting); (5) sociodemographic context (country; population dispersion; income level of the country; socioeconomic level of the country; maternal, early neonatal and neonatal mortality rates); (6) implementation strategies (type; name; group; description; actor; action; target; temporality; dose; implementation outcomes measured; justification); (7) implementation process (time duration of implementation or speed; quality of programme delivery or percentage of adherence to SCC; quantity or number of births in which SCC was used); (8) frameworks, theories or models used (during design, implementation or interpretation of the intervention); (9) implementation outcomes (acceptability; adoption; acceptance; costs; feasibility; fidelity; penetration; sustainability). (10) final considerations (limitations; brief summary; other notable observations). Modifications to the WHO SCC will also be reported. Any disagreements between reviewers will be resolved through discussion and consensus or, if necessary, by a third reviewer.

Implementation strategies will be classified according to the Expert Recommendations for Implementing Change taxonomy¹⁸ and described considering the criteria proposed by Proctor et al: (1) name recognised in literature; (2) definition; (3) specificity (actor, action, target, temporality, dose, implementation outcome and justification).¹⁹

The implementation process will be measured by indicators of speed, quality and quantity. Speed is the duration of the implementation, quality can refer to the fidelity or competence in programme delivery, and quantity can refer to how much of the target population is served by the intervention.²⁰ At a minimum, we will use one measure for each type of indicator of speed, quality and quantity, specifically duration of implementation measured in months, percentage of adherence to WHO SCC, and number of individuals for which WHO SCC is used, respectively.

Implementation outcomes will be classified according to Proctor et al: acceptability, adoption, acceptance, costs, feasibility, fidelity, penetration and sustainability.²¹

Step 5: compilation, summary and reporting of results

Descriptive analysis of the study characteristics will be summarised. The included studies will be categorised according to the objectives proposed in the review, as follows:

• Geographic context, birth setting and socio-demographic context.

• SCC implementation strategies used in successful and unsuccessful implementation. The success of the implementation will be defined as 80% adherence to the use of the SCC or more.

Percentage of adherence: ${\displaystyle \frac{\mathrm{A}\mathrm{v}\mathrm{e}\mathrm{r}\mathrm{a}\mathrm{g}\mathrm{e}\mathrm{n}\mathrm{u}\mathrm{m}\mathrm{b}\mathrm{e}\mathrm{r}\mathrm{o}\mathrm{f}\mathrm{c}\mathrm{o}\mathrm{m}\mathrm{p}\mathrm{l}\mathrm{e}\mathrm{t}\mathrm{e}\mathrm{d}\mathrm{i}\mathrm{t}\mathrm{e}\mathrm{m}\mathrm{s}}{\mathrm{N}\mathrm{u}\mathrm{m}\mathrm{b}\mathrm{e}\mathrm{r}\mathrm{o}\mathrm{f}\mathrm{i}\mathrm{t}\mathrm{e}\mathrm{m}\mathrm{s}\mathrm{o}\mathrm{n}\mathrm{t}\mathrm{h}\mathrm{e}\mathrm{S}\mathrm{C}\mathrm{C}\mathrm{i}\mathrm{m}\mathrm{p}\mathrm{l}\mathrm{e}\mathrm{m}\mathrm{e}\mathrm{n}\mathrm{t}\mathrm{e}\mathrm{d}}\times 100}$

• Gaps in the literature and directions for future studies.

Step 6: synthesis of evidence

To analyse the findings, an expert panel of SCC implementers and researchers will be consulted in order to interpret the findings and draw appropriate conclusions. The panel will have representation from Ariadne Labs (Harvard T.H. Chan School of Public Health and Brigham and Women’s Hospital) and the Research Group Quality in Health Services - QualiSaúde (Federal University of Rio Grande do Norte). The panel discussion will be held virtually, with an invitation sent by email, containing information about the purpose of the panel, objectives of the panel discussion, preliminary findings and discussion questions. The scoping review timeline is detailed in table 3.

Table 3.

Scoping review timeline

Stage	Start	Conclusion
Preparation of the project pilot and definition of the search strategy	May 2023	June 2023
Protocol construction	July 2023	December 2023
OSF protocol registration	November 2023	January 2024
Selection of studies (Covidence)	January 2024	February 2024
Data extraction and coding	March 2024	April 2024
Panel with experts	May 2024	May 2024
Analysis and interpretation of results	May 2024	Jun 2024

Patients and public involvement

Patients or the public were not involved in the design, or conduct, or reporting, or dissemination plans of our research.

Ethics and dissemination

Due to the nature of the study, ethical review is not required. We plan to submit the manuscript for publication in a peer-reviewed journal and present the findings at national and international scientific meetings.

Ethics statements

Patient consent for publication

Not applicable.