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A 29-item checklist dramatically increased the frequency with which providers in an Indian hospital took simple steps to protect the health of women in childbirth and their babies, such as washing their hands with soap before an exam or using a sterile blade to cut the umbilical cord.

When paired with training and education, checklists have been shown to be a useful tool in reducing errors and improving outcomes in surgery and intensive care units. An international group of researchers, including Drs. Atul Gawande and Jonathan Spector of the Harvard School of Public Health, are testing whether it helps in delivery rooms throughout the developing world.


“The burden of preventable deaths in moms and babies, particularly in low-resource settings, is enormous,” said Spector, a Harvard research scientist and neonatologist at Massachusetts General Hospital.

Each year, about 300,000 women die in childbirth. Millions of deliveries result in stillbirths or in newborn deaths.

The single-hospital study, published Wednesday in the online journal PLoS ONE, helped to lay the groundwork for a larger one in which researchers, with the help of $14.1 million from the Bill & Melinda Gates Foundation , will track about 170,000 births in 120 Indian hospitals, half of which will use the World Health Organization Safe Childbirth Checklist program. That study will test whether the checklist reduces the number of deaths in childbirth.

The pilot, which followed 499 births before the checklist was implemented and 795 afterward, did not show a statistically significant drop in deaths, but it wasn’t designed to, Spector said. What it did show is that using the checklist changes behavior.

That’s important, he said, because “in all likelihood, if the practice is no different, it’s unlikely that the outcomes would be different.”

The use of the checklist at the hospital in Karnataka, India, was monitored in each delivery by nurses who were hired from another hospital to be observers.


Health workers properly washed their hands and wore gloves while performing an initial vaginal exam in 98 percent of cases when prompted with the checklist, up from just 1 percent before the checklist was implemented. Use of a sterile blade to cut the umbilical cord jumped to 99 percent from 12 percent. Use of a drug that helps to prevent maternal hemorrhaging if administered immediately after birth increased to 69 percent from 8 percent.

After training with the checklist, health workers discussed family planning options with mothers in 95 percent of cases, up from less than 1 percent. That’s important not just to ensure proper spacing of pregnancies, Spector said.

“Childbirth, in these settings, is many times the most risky procedure or condition that a mom will have in her lifetime,” he said. “Unintended pregnancies put the mom at incredible risk.”

Spector said the results are “highly encouraging” but more research is needed to show whether the checklist can improve the safety of childbirth. The larger study is still in the planning stages, but the researchers hope to begin enrolling women this fall.

Chelsea Conaboy can be reached at cconaboy@boston.com. Follow her on Twitter @cconaboy.