Achieving the desired reduction in preventable maternal and child mortality remains the unfinished agenda of the Millennium Development Goals (MDGs) [1–4]. This has remained unachieved despite knowing what works for reducing maternal and child mortality in developing country contexts for many years [5, 6] It has been estimated that globally, better care during labor and birth, and care of new-borns immediately after birth can avert up to 1.49 million maternal and new-born deaths and still births.(6) There is an urgent need to fill the gap between evidence and its translation to practices during care provision, particularly in developing country settings.

Nowhere is the need for filling this gap greater than in India. With the burden of 0.76 million neonatal deaths, India tops the list of countries with high Neonatal Mortality Rate (NMR) [7]. India has infant and under-five child mortality rates of 42 and 52 per 1000 live births respectively, and about 70 % of infant deaths and more than half of under-five child deaths in India occur in the neonatal period, the first 4 weeks of life [8].

While the infant mortality rate (IMR) has declined steadily, early neonatal mortality rate (ENMR) has virtually remained static since the last decade [9]. Considering the fact that neonatal deaths account for up to 40 % of under-5 deaths [3], the need for focusing on perinatal care in India is an urgent local and global priority.

The three-delay framework (decision to seek, reaching, receiving adequate care), used for understanding maternal and newborn mortality in developing countries applies well to the Indian context for maternal and newborn mortality [10–12] Acting on the best available evidence that having mothers deliver in institutions rather than homes improves birth outcomes, India invested heavily on improving institutional delivery rates through programs such as Janani Suraksha Yojna (JSY a conditional cash transfer program for women delivering at institutions.). Rates of institutional delivery have more than doubled since the advent of National Rural Health Mission (NRHM), and currently more than 74 % of total births in India are occurring at institutions [13]. However, various studies have failed to show a commensurate reduction in maternal and neonatal mortality [14, 15]. Thus, just having a contact with the health system for deliveries has not proven to be enough for improving outcomes, which suggests a need to focus on the quality of care during these contacts. Experience from JSY also indicates that while the focus on bringing women to institutions may have influenced the first and second delay in care, the third delay, i.e., in timely and high-quality care provision at institutions is still a challenge [14].

It is well known that the capacity for quality of care for maternity services is influenced by skills of health workers in performing essential practices, availability of essential resources, presence of appropriate and evidence-based guidance for action, and an overall enabling environment including effective organization of health care services [1–4]. In the Indian context, as in many settings, accountability and motivation of health workers to translate this capacity for quality into action are additional important influencers of quality of care. The Indian government has developed many guidelines focusing on quality of perinatal care and has invested resources on training health workers through skill building programs for childbirth related care [16, 17]. However, these initiatives have not translated into improved quality of care. A recent study in Delhi points out the widespread non-adherence to evidence-based practices in both public and private sector maternity care institutions [18]. Thus, in the Indian context, there is a strong felt need to develop and test tools and technologies that can help health workers to translate evidence into action.

The WHO Safe Childbirth Checklist has been considered as a promising frugal technology aiming at improving childbirth related care [19]. Building upon the success of the Surgical Safety Checklist in improving quality outcomes in health practices [20], this checklist was developed by WHO to support health workers to perform essential practices and prevent avoidable childbirth-related deaths [21]. The SCC targets high impact best practices around 4 pause points that occur in almost every delivery: admission, pushing, just after delivery and pre-discharge. In a single facility study in Karnataka, the use of SCC significantly improved the delivery of essential safety practices by health workers during childbirth [22]. However, while the study provided initial evidence on the effectiveness of SCC for improving service quality, it reported limitations regarding generalizability of and sustainability of findings due to the study design, nature of intervention, and setting of the study [22]. Considering the urgent need for India to identify solutions to improve quality of childbirth care at scale, evaluation of interventions that promote uptake and adherence with a simple technology like the SCC within realistic program implementation settings represents an important research priority for the country. Moreover, the WHO SCC multi-country collaboration is keenly interested in implementation experience and evidence from multiple settings to generate guidance on how the SCC should be used on a global scale [23].

Responding to the needs described above, a large quasi-experimental design study was conducted in 200 health facilities in the state of Rajasthan in India to understand the effectiveness of the SCC on childbirth-related outcomes within the ‘real-world’ program and administrative framework in the country. While the larger study was designed with a view to capture effects of SCC use on client outcomes, a smaller sub-study was conducted to understand the pathway by which the SCC changes these outcomes. Through direct observations in the labour rooms, we tried to assess effectiveness of SCC in bringing changes in adherence to safe care practices by the health workers in intervention facilities as compared to the comparison facilities. In this paper, we are reporting the results of this observational study, nested within the larger quasi-experimental design study, to assess whether women receive more life-saving practices during labour, delivery, and the immediate postpartum period in facilities where SCC was introduced compared to women in facilities where the SCC was not introduced. A separate evaluation is going to assess the impact of the SCC use on in-facility perinatal mortality rates.

When a logistic regression model with robust standard error was run for each of the 28 practices adjusting for covariates of clustering by health worker, and a composite index for supplies, health worker, health worker categories) and testing the significance of the interaction term estimating the difference in difference (i.e., time-baseline and endline-and group-intervention and comparison) 16 of the 28 practices had improved significantly more in the intervention than in the comparison group. During the first pause point partograph use, preeclampsia management, HIV testing of mothers and companion briefed on danger signs were statistically significant (p < .001). In the second pause point, giving oxytocin to mothers within one minute of delivery and appropriate new born thermal management were statistically significant. In the third pause point blood loss assessment, appropriate maternal infection management, new born assessment for antibiotics, initiation of breast feeding and briefing companion on danger signs were statistically significant. In the fourth pause point appropriate new born infection management, new born feeding assessment and appropriate maternal infection management were statistically significant. These practices in endline intervention group was higher than all other groups. Since the P value of Less than 0.0017 was the cut off due to Bonferroni’s correction the difference in difference of proportion of these practices were statistically significant.

Figure 1 illustrates the average number of evidence-based practices included in the SCC performed on each client in intervention and comparison groups at baseline and endline. The mean number of practices increased from 4.5 practices to 6.4 in the comparison group and from 4.3 practices to 17.9 practices in the intervention group.

On average a client in the intervention facility received 11.5 more SCC (95 % CI-8.5–14.6)) best practices than a client in comparison sites controlling for baseline values; this difference was statistically significant (p < 0.001).

In this study, we evaluated the effectiveness of a SCC in ensuring adherence to safe childbirth related practices known to have high impact on reducing preventable maternal and neonatal mortality around the time of delivery as well as an optimal implementation approach for increasing providers’ use of the SCC in ‘real-life’ facility settings. We observed that an overwhelming majority of providers in the intervention facilities did use the SCC during the delivery process. Introduction of the SCC supported by a simple implementation package resulted in a clear improvement in adherence with SCC essential practices in the facilities where it was introduced as compared to the facilities where it was not. Out of the 28 essential practices, women in the intervention facilities received nearly 12 more practices than in the comparison facilities. Given the findings of the study, it appears that introduction of the SCC in association with a light implementation package may be an effective approach for helping to close the “know-do” gap in intrapartum care best practices.

During the study, it was observed that the SCC helped to strengthen the quality of initial assessment and appropriate referral of the women at the time of admission. Inappropriate and delayed initial assessment and referral at the time of admission, classically categorized as the third delay, are major contributors to maternal and new-born morbidity and mortality [10–12]. It is apparent from our observations that the SCC has a good potential to reduce this delay through better assessments at the time of admission.

Adherence to several important maternal clinical care practices proven to reduce the incidence and mortality due to complications like post-partum haemorrhage improved more in the intervention facilities (e.g., adherence with immediate postpartum administration of oxytocin for reduction of PPH.)

Study results also demonstrated increased adherence with several lifesaving interventions for the newborn such as appropriate thermal management which included drying of the baby with dry towel, timely and appropriate resuscitation and immediate initiation of breastfeeding. It is noteworthy that in spite of large amount of resources spent on national training initiatives like trainings for Skilled Birth Attendance (SBA) or the national newborn survival training program (‘Navjat shishu Suraksha Karyakram’-NSSK), the practices related to essential newborn care like immediate initiation of breastfeeding are still sub-optimal in many parts of India [24–28]. Thus the improved adherence with lifesaving practices by the health workers in SCC intervention sites highlights the potential of SCC in helping translate knowledge and skills into practice.

Assessment of the well-being of the mother and newborn both at the time of admission and at the time of discharge also improved significantly more in the facilities where the SCC was used. This reflects the important role of the SCC in standardizing facility-based procedures for effective admitting and discharging the clients. Assessments of client at the time of admission to review whether care needed for a client’s condition can be provided at the facility and assessments at the time of discharge to ensure that a client with any imminent complications is not discharged into communities, are important system characteristics to improve maternal and newborn health outcomes. However, supportive services such as counselling for Family Planning and discharge counselling on danger signs did not improve significantly and this, we believe, was due to the scarcity of adequate human resources to support optimal discharge processes for mother and newborn.

An important innovation of the SCC implementation strategy in this study involved slight modification in the SCC to include documentation of maternal, foetal and newborn vital signs at key pause points followed by a provider signature. We believe that this modification of the SCC helped to promote use of the SCC at the point of care as a part of the client record and also increased provider accountability since the SCC effectively became a part of the client records. Many studies have emphasized the importance of accountability mechanisms in ensuring delivery of quality services to clients [29–31]. In the absence of robust systems to measure quality of services rendered to clients, accountability of providers to provide quality services is low in public health facilities in India. We believe that in this context, the SCC, by virtue of the mandatory recordings of the client vitals with provider signature on the SCC, has been effective in increasing the accountability of the providers which in turn has resulted in increased provider adherence with essential practices.

During the study period, a significant improvement was seen in certain practices in comparison facilities also, such as, the use of oxytocin for active management of third stage of labour, cord cutting with sterile blade and appropriate newborn thermal management. Since these practices are dependent on availability of relevant supplies, It is likely that the project component to ensure availability of essential supplies in both the intervention and comparison facilities contributed in part to this observed increased adherence with these best practices Additionally, as a part of a nursing education strengthening national initiative, in-service provider trainings in some of the comparison facilities were conducted by the government, which may explain the improvement in adherence to these practices. It is worth mentioning that among all the practices listed in the SCC, adherence with routine care practices (relevant for every mother and newborn) increased the most (such as administration of immediate post-partum oxytocin for active management of third stage of labour, initiation of immediate breast feeding). Adherence with the more complex SCC practices which require greater provider knowledge, experience and skills (e.g., resuscitation of a newborn and correct completion of the partograph) improved at a lesser rate than that for simpler routine best practices. Of note, adherence with practices rooted in social-cultural and behavioural context like hand-washing and skin-skin to contact did not improve as a result of using the checklist.

The SCC was developed by WHO to improve adherence to life saving practices in the intra- and immediate postpartum period. The SCC was piloted in one facility of Karnataka state of India in 2010, where in controlled settings, it increased adherence to some practices [22]. A similar study was conducted in one tertiary care centre of Sri Lanka where adherence to best practices as well as adherence to SCC was studied [32]. However, since both these studies were limited to just one facility and were done in controlled settings, there was a need for evidence on the effectiveness of the SCC at a scale and in resource constrained settings of developing countries like India.

The SCC, like any other checklist, is supposed to act as a reminder tool for the user, to help in minimize human errors and promote reliable human actions during complex procedures such as surgery and childbirth. However, the learning of the program in which the study was nested throws a whole new light on the way the SCC works in the developing country contexts such as India. As acknowledged globally, provider adherence to clinical practices is a function of multiple influencing factors, including provider competency and motivation and availability of essential commodities, equipment and human resources among other factors [1–4].

Two additional important determinants of adherence with best practices in the Indian context include provider accountability and nurse empowerment to participate in clinical decision making and initial management of complications. We believe that in the Indian context, the modifications in the SCC as part of the implementation strategy helped to ensure that the SCC functioned not only as a memory tool for providers but also as a framework for improving accountability (5,6) of providers due to a blended use of the SCC as checklist and a partial patient record. The adapted SCC, by virtue of being recommended by the government for use, being the part of case records,, and having added prompts for managing complications such as birth asphyxia, severe pre-eclampsia and eclampsia and post-partum haemorrhage, empowered the nurses to do initial management of maternal and newborn complications, which earlier they used to refer to doctors. Since a vast majority of vaginal deliveries are conducted by the nurses in the public health facilities, this empowerment of nurses has resulted in improved prevention and initial management of maternal and newborn complications. This mechanism of effect of the SCC has a major implication for similar resource constrained settings globally where deliveries are conducted mainly by nurses and availability of doctors is mostly sub-optimal.

Since additional programmatic components were limited to Jhpiego staff facilitating the activities, and mostly system’s resources were used for orientations and availability of any needed resources, the results of this study can be generalized to other low and middle Income countries with similar settings although further adaptation of the implementation strategy may need to be done to suit these settings. The fact that the SCC implementation strategy in this study was firmly grounded in the local public health system makes the possibility of scale up more feasible.

Key features of the implementation package that are likely generalizable to other settings include implementation within the local health system context with local system stakeholders, initial modification of the SCC based on local context, strategies to promote integration of the SCC into routine processes of maternity care (e.g., documentation of vital signs directly onto the SCC and use of the SCC as a partial individual patient record), strategies to promote provider accountability (e.g., provider signature after documentation of vital signs on SCC), empowerment of lower provider cadres to implement best practices for complications, and support for key commodities. Further research is needed into implementation strategies that may increase adherence with the most complex SCC interventions (such as complications care) and with SCC practices linked to behavioural and cultural resistance (e.g., handwashing, skin to skin care for newborn, etc.)

The study did have few limitations. Potential Hawthorne effect would have occurred due to observation of practices. But was minimized by silent observation without affecting the work there might have been some effect due to observation. But this remained the same in intervention and comparison facilities. We had a different set of observers during baseline and endline as we had nursing interns as observers. But they were trained in a standardized way using the same tools and the same trainers.

Use of the SCC and provider performance of best practices increased in intervention facilities reflecting improvement in quality of facility childbirth care for women and new-born in low resource settings.