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Randomized Controlled Trial
. 2020 Sep;5(9):e002268.
doi: 10.1136/bmjgh-2019-002268.

Does adherence to evidence-based practices during childbirth prevent perinatal mortality? A post-hoc analysis of 3,274 births in Uttar Pradesh, India

Katherine Ea Semrau  1   2   3 , Kate A Miller  4 , Stuart Lipsitz  4   3 , Jennifer Fisher-Bowman  4   5 , Ami Karlage  4 , Bridget A Neville  4 , Margaret Krasne  6 , Jonathon Gass  4   7 , Amanda Jurczak  4 , Vinay Pratap Singh  8 , Shambhavi Singh  8 , Megan Marx Delaney  4 , Lisa R Hirschhorn  9   10 , Bhalachandra Kodkany  11 , Vishwajeet Kumar  8 , Atul A Gawande  4   12   13
Affiliations
Randomized Controlled Trial

Does adherence to evidence-based practices during childbirth prevent perinatal mortality? A post-hoc analysis of 3,274 births in Uttar Pradesh, India

Katherine Ea Semrau et al. BMJ Glob Health. 2020 Sep.

Abstract

Background: Evidence-based practices that reduce childbirth-related morbidity and mortality are core processes to quality of care. In the BetterBirth trial, a matched-pair, cluster-randomised controlled trial of a coaching-based implementation of the WHO Safe Childbirth Checklist (SCC) in Uttar Pradesh, India, we observed a significant increase in adherence to practices, but no reduction in perinatal mortality.

Methods: Within the BetterBirth trial, we observed birth attendants in a subset of study sites providing care to labouring women to assess the adherence to individual and groups of practices. We observed care from admission to the facility until 1 hour post partum. We followed observed women/newborns for 7-day perinatal health outcomes. Using this observational data, we conducted a post-hoc, exploratory analysis to understand the relationship of birth attendants' practice adherence to perinatal mortality.

Findings: Across 30 primary health facilities, we observed 3274 deliveries and obtained 7-day health outcomes. Adherence to individual practices, containing supply preparation and direct provider care, varied widely (0·51 to 99·78%). We recorded 166 perinatal deaths (50·71 per 1000 births), including 56 (17·1 per 1000) stillbirths. Each additional practice performed was significantly associated with reduced odds of perinatal (OR: 0·82, 95% CI: 0·72, 0·93) and early neonatal mortality (OR: 0·78, 95% CI: 0·71, 0·85). Each additional practice as part of direct provider care was associated strongly with reduced odds of perinatal (OR: 0·73, 95% CI: 0·62, 0·86) and early neonatal mortality (OR: 0·67, 95% CI: 0·56, 0·80). No individual practice or single supply preparation was associated with perinatal mortality.

Interpretation: Adherence to practices on the WHO SCC is associated with reduced mortality, indicating that adherence is a valid indicator of higher quality of care. However, the causal relationships between practices and outcomes are complex.

Funding: Bill & Melinda Gates Foundation.

Trial registration details: ClinicalTrials.gov: NCT02148952; Universal Trial Number: U1111-1131-5647.

Keywords: maternal health; obstetrics; public health.

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Conflict of interest statement

Competing interests: AAG receives royalties for books and essays, including on improving quality and delivery of healthcare using checklists. AAG is also the Chairman fo the Board of Haven, the health care venture formed by Amazon, Berkshire Hathaway, and JPMorgan Chase.

Figures

Figure 1
Figure 1
Cumulative adherence to practice and perinatal mortality.
See this image and copyright information in PMC

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