Kaplan, Lennart Christian (57200420651); Delaney, Megan Marx (57195302212); Roddewig, Pia (60030129800); Singh, Shambhavi (56175946100); Molina, Rose L. (56919216000); Diba, Farah (57212151576); Tuller, Danielle E. (57192266591); Bobanski, Lauren (57209740083); Hashmi, Ashfa (57209215972); Marthoenis, Marthoenis (39762456200); Richert, Katharina (57142647600); Ichsan, Ichsan (55844645400); Singh, Vinay Pratap (57192276096); Muhsin, Muhsin (55995036900); Kumar, Vishwajeet (24401275800); Sofyan, Hizir (6506647921); Vollmer, Sebastian (24460878700); Semrau, Katherine E.A. (6603281616)
Importance The World Health Organization (WHO) Safe Childbirth Checklist (SCC) has been adapted and implemented in at least 35 countries. Consistently, the SCC has shown increased adherence to practices, but there are mixed results regarding its association with health outcomes in different settings. Objective To examine the association of SCC implementation with mortality, accounting for variations in evidence-based practices (EBP) adherence. Design, Setting, and Participants In this meta-analysis, data were pooled from 3 cluster randomized trials of the SCC (January 1, 2014, to December 31, 2017). Intention to treat (ITT) and a complier average causal effect analysis (CACE) on EBPs and perinatal mortality were estimated via a generalized linear model. The primary facilities were in Uttar Pradesh, India; basic emergency obstetric facilities were in Aceh, Indonesia; and primary and secondary health centers were in Khyber Pakhtunkhwa, Pakistan. Interventions In India, the 8-month SCC intervention involved facility engagement, a launch event, and 8 months of tapered coaching. In Indonesia, the 6-month SCC intervention included 11 coaching visits. In Pakistan, the 12-month SCC intervention included light touch external monitoring, skills training, and supplies assessment. Main Outcomes and Measures Primary outcomes were stillbirth and perinatal and early neonatal mortality. Secondary outcomes were adherence to 15 EBPs, facility supply availability, and safety culture perceptions. Results Pooled data included 169 511 births, supply assessments from 163 facilities, and 6298 observed deliveries for EBPs and health workers’ perceptions on safety culture. Mortality did not differ in the full sample; however, during months when EBP observations were conducted, stillbirth rates in the intervention facilities were lower by 9.8 per 1000 births (95% CI, −18.5 to −1.1; P =.03; q =.05) in the ITT analysis and 14.5 per 1000 births (95% CI, −27.2 to −1.7; P =.03; q =.05) in the CACE analysis compared with control facilities. EBP adherence was higher by 3.6 practices (95% CI, 3.3 to 4.1; P <.001; q =.001) in the ITT analysis and 6.0 practices (95% CI, 5.3 to 6.8; P <.001; q =.001) in the CACE analysis in intervention facilities. Conclusions and Relevance In this meta-analysis, SCC use in lower-middle-income settings was associated with increased EBP adherence and lower rates of stillbirths when EBPs were directly observed. Further research is needed to identify additional factors to optimize SCC’s potential impact on maternal and newborn safety outcomes. © 2026 Kaplan LC et al.
Georg-August-University of Göttingen, Göttingen, Germany; Ariadne Labs, Harvard T.H. Chan School of Public Health, Brigham and Women’s Hospital, Boston, MA, United States; Department of Economics, Centre for Modern Indian Studies, University of Goettingen, Göttingen, Germany; Community Empowerment Lab, Lucknow, India; Beth Israel Deaconess Medical Center, Boston, MA, United States; Community Health Nursing Department, Faculty of Nursing, Universitas Syiah Kuala, Banda Aceh, Indonesia; World Health Organization Country Office, National Institutes of Health, Chak Shahzad, Islamabad, Pakistan; Department of Psychiatry and Mental Health Nursing, Universitas Syiah Kuala, Banda Aceh, Indonesia; Center for Evaluation and Development, Mannheim, Germany; Medical Research Unit, School of Medicine, Universitas Syiah Kuala, Banda Aceh, Indonesia; Department of Microbiology, School of Medicine, Universitas Syiah Kuala, Banda Aceh, Indonesia; Tsunami and Disaster Mitigation Research Center, Universitas Syiah Kuala, Banda Aceh, Indonesia; Faculty of Medicine, Universitas Syiah Kuala, Banda Aceh, Indonesia; Statistics Department, Universitas Syiah Kuala, Banda Aceh, Indonesia; Centre for Modern Indian Studies (CeMIS), Georg-August-University of Göttingen, Göttingen, Germany; Division of Global Health Equity, Brigham and Women’s Hospital, Boston, MA, United States; Department of Medicine, Harvard Medical School, Boston, MA, United States
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