Saving babies' lives in Rajasthan

A simple checklist is making a remarkable difference in the labour rooms of Rajasthan

Find out more about this programme (PDF)

Too many babies die from preventable causes in their first month of life. Despite the best efforts of maternity and medical staff, simple checks and practices are often overlooked or forgotten.

According to new data and medical staff in the Indian state of Rajasthan, an innovative to-do list has the potential to save the lives of mothers and babies. What began as a knowledge tool to jog their memories, the checklist is having an impact as a framework for care, management, training and resource allocation.

The Safe Childbirth Checklist

The WHO’s Safe Childbirth Checklist is a simple, paper-based tool which was developed to support health workers in low-resource settings to perform essential practices and prevent avoidable childbirth-related deaths. The Checklist suggests actions at four stages (before, during and immediately after birth, as well as on discharge) aimed at the most common causes of maternal mortality (haemorrhage, infections, hypertensive disorders, and obstructed labour), intrapartum related stillbirths, and neonatal mortality (birth asphyxia, infection, and complications of prematurity).

Knowledge tool

“Let me tell you the biggest advantage of this checklist. Earlier, we did not know how to handle newborns, what position to keep them in, or anything related to their care. If a baby had some problem like birth asphyxia, we would get very nervous. In such a situation, we used to turn the baby upside down and hit the baby hard on its back. That’s about all we did and quickly referred the baby to a [better-equipped medical] centre. Imagine the chances of that baby’s survival with the referral centre more than 100 kilometres away. Now, we have learned about the golden minute- the first minute after birth. We can do much more to help the baby survive.”

– Auxiliary Nurse Midwife Kiran Khatri, Community Health Centre, Bajju

Measuring impact

In Rajasthan, 101 health facilities across seven districts are now implementing the Checklist programme with support from Jhpiego. Another 99 facilities in six districts act as control sites.

The Public Health Foundation of India conducted an independent evaluation of the programme in 34 high-load facilities, covering 137,039 live births. The evaluation found that after a one year period, there were 11% fewer stillbirths and very early newborn deaths (ie. deaths within the first 48 hours) in Checklist facilities compared to the control sites.

The programme saved 375 babies at a cost of $3,783 per stillbirth and very early newborn death averted and $63 per life year saved.

Making a real difference

The data shows a clear improvement in adherence to essential lifesaving practices, together with wider improvements in the care environment, such as hygiene and cleanliness. The Checklist has made maternity staff acutely aware of the impact of simple yet essential newborn care practices on newborn morbidity and mortality. For example, use of the Checklist has led to a significant improvement in timely diagnosis and management of severe pre-eclampsia/eclampsia using magnesium sulphate. More newborns are being dried immediately after birth, preventing them from hypothermia, breastfeeding within one hour of birth has increased (from 62% to 88%), and more newborns are being monitored for respiratory rate within one hour of birth.

Changing behaviour

Health workers acknowledged that in some cases it was a challenge introducing the Checklist. Some thought it would be another layer of bureaucracy, adding to their workloads. However, in practice they have found it has improved the way they work. The programme has demonstrated that it takes time to shift health worker behaviours and establish new practice norms. It requires regular supervision and follow up in health clinics after the initial training to ensure good practices are sustained in the labour room. With training and mentorship, the Checklist has empowered maternity staff with the knowledge they need to make life-saving decisions for mothers and children without always waiting for a doctor’s opinion.

Saving lives

“Just a few days back, a patient got postpartum eclampsia. Earlier, my staff would have had no knowledge or available medicines to help her. We would have referred her to the district hospital, Dausa, which is more than an hour away. Anything could have happened to her in that period. But now, the situation is different. I instructed my nurse to quickly get magnesium sulphate. We positioned the patient so she would not choke. We administered the prescribed dose and after giving this first line of treatment, referred her to the [better-equipped medical] centre. On contacting the referral centre, we learned that by the time she reached Dausa, she was already feeling much better. All of us felt so happy that we could save this life. We moved around with a big smile that entire day.”

– Dr Manisha Meena, Medical Officer (in charge) , Community Health Centre, Mandawar

In the state of Rajasthan, for every 1,000 children born, 38 die within the first month.

In the Indian state of Rajasthan, for every 1,000 children born, 38 die within the first month. The Safe Childbirth Checklist is serving as a framework to help bring this number down by boosting the knowledge and confidence of nurses to act in the absence of a doctor, increasing availability of life-saving drugs, and improving hygiene, cleanliness and the overall of quality of care.

The Checklist has been incorporated into the Government of India’s maternal newborn health tool kit, and is being rolled out to other states.

Reducing newborn deaths in Rajasthan

For more on the Safe Childbirth Checklist, visit

Jhpiego’s website.

To discover the personal stories behind the Safe

Childbirth Checklist, read Ensuring quality, saving

lives‘.

Photos courtesy of Indrani Kashyap (Jhpiego) and Kate Holt