Table 1.

Adaptation to create the BetterBirth (BB) intervention package used in the randomized control trial

	Karnataka Pilot	First adaptation	Second adaptation	RCT
Leadership engagement	Study lead introduced to district and facility leadership	Non-standardized introduction to district and facility leaders	Formalized introduction at district and facility including strong focus on motivation to drive adoption	Same as in phase II
Education of facility staff	1-day training on the SCC supported by instructional video, and hands-on simulation	3-day training for staff (2 days didactic, 1-day coached practice using the SCC)	Semi structured launch including 1–2-day workshop introducing SCC, problem solving, and strong focus on motivation including video and anthem	Structured 2-day launch with increased focus on implementation of the SCC with day 2 on-site for official start
Coaching support	Core team of head of the hospital and senior physician and labor nurse supplemented by physician from the study team	Physician-led team of physician and nurses coaching birth attendants	Peer-to-peer model: Nurse coaches for birth attendants (behavior change), physician coach facility leader (systems change and SCC leadership), and childbirth quality coordinator	Same with additional focus on district lead to build support for SCC
	Coaching provided during normal clinical routines supplemented every 2 weeks by study physician	Coaching provided Every 1–2 weeks for 4–6 weeks		Coach training using standardized curriculum focused on coaching skills to drive behavior change and barriers framework (opportunity, ability, motivation) with strong focus on motivation
	Coach training through review of SCC	Coach training through 2-day, on-site workshops focusing on clinical skills	Coach training focused more on QI approaches and behavior change
Data feedback loop	Subset of baseline observation data feedback to staff to identify quality gaps	None	Paper-based system used to capture and review observation data by coaching team to identify persisting gaps and behavior change. Apps used to capture study-related data	Robust app-based system to provide real-time data feedback on coach observations and essential birth supplies to BB team, facility, and district. All study data continued to be captured by existing apps
Safe birth supplies (SBS) availability	Largely available	Supply chain gaps	Increased focus of coach TL to help the facility head and district leaders leverage existing resources to address gaps	Strengthened focus for coaching and advocacy at facility and district levels for strengthening EBS availability

TL physician coach team leader, EBP essential birth practices, RCT randomized control trial