**4. Discussion**

antibiotics should be administered immediately, the discharge should be delayed and special care or monitoring should be given. Indications for antibiotics in newborns include: maternal antibiotics administration, neonatal temperature <35°C or ≥38°C, neonatal respiratory rate >60 per minute or <30 per minute; chest indrawing, grunting, or convulsions; or poor movement on stimulation, umbilicus redness extending to skin or draining pus; poor movement on stimulation; or has stopped breastfeeding well. It is imperative that babies with infection or risk factors for infection are treated immediately to prevent infection-

This checklist item prompts the healthcare worker to confirm before the mother and baby are discharged from the birth facility; that adequate breastfeeding has been established. In a baby; the signs of feeding well are active breastfeeding every 1–3 h with urination and bowel motions. If the newborn is not feeding well, the healthcare worker should delay discharge and

This checklist item ensures the healthcare worker will remember to offer family planning options to the mother before her discharge. Recall that after a live birth, the recommended interval before attempting the next pregnancy is around 2 years. Family planning helps to prevent unwanted pregnancies and safeguards the mother. The healthcare worker should confirm that family planning options have been discussed with and offered to the mother before discharge. Family planning options include intrauterine devices, implantable rods, long-acting injectable progesterone (Depo-Provera), oral contraceptives, tubal ligation and condoms. Intra-uterine devices can be inserted immediately after childbirth, during or after the 6 weeks postpartum visit. Implantable devices (Implanon, Jadelle) can be inserted immediately after childbirth or after the puerperium. Breastfeeding mothers are generally advised not use combined hormonal contraceptives before 6 months postpartum. Health care workers using Checklist should also take the opportunity before discharge of the mother to discuss optimal birth spacing and schedule a tubal ligation procedure for moth-

*3.2.4.8. Arrange follow-up and confirm mother/companion will seek help if danger signs appear* 

This checklist item ensures the healthcare worker arranges for routine follow-up for both the mother and baby. This must be arranged for before the mother-baby pair are discharged from the hospital. A healthy mother and baby at the time of discharge may develop complications after they have returned home. Mothers (and birth companions) should thus be educated to recognise danger signs themselves so care can be requested promptly: The danger signs are:

related complications.

106 Selected Topics in Midwifery Care

ers who wish.

*after discharge*

*3.2.4.6. Is baby feeding well?*

assist the mother in establishing good feeding.

*3.2.4.7. Discuss and offer family planning options to mother*

Using the WHO Safe Childbirth Checklist serves as a powerful reminder of all that needs to be done during the critical period of childbirth. It also highlights the deficiencies in maternity service delivery: the dearth of manpower resources; the absence of antibiotics, anticonvulsants, antihypertensives and oxytocics; the lack of necessary supplies and commodities such as gloves, antiseptic lotions, clean towels, swabs, syringes; the unavailability of water supply and electricity; and the sociocultural determinants that make women present to health facilities in extremis.

Gaining, and sourcing for dedicated healthcare workers to champion the cause of the childbirth checklist revealed the dearth of human resources for health. Advocacy and dedication are vital at this point to introduce the checklist for use in maternity settings. Making the checklist available at the point of care is the next hurdle. Simple paper and ink may not be available, but a satisfactory buy-in by the facility managers ensure the checklist is printed and available at the necessary points. The need to ensure the available number of healthcare workers using the childbirth checklist can satisfactorily carry out the evidence base practices lead to training and workforce skills enhancement. This strengthened the services provided at the facilities.

On admission, using the checklist immediately exposes the absence of facility guidelines and criteria on whom to refer; thus effectively using the checklist strengthens the facility to provide guidelines and facility criteria for referral. At the same time; risk factors for poor maternal/perinatal outcomes such as prolonged drainage of liquor, fever, high blood pressure and proteinuria are easily detected because the healthcare worker must check these in order to tick the checklist. Same for the use of partograph; to tick the checklist, the healthcare worker has to open and use the partograph. To tick and confirm that mother or companion will call for help during labour if needed, the healthcare worker has to first counsel and educate the mother and her companion on the danger signs in pregnancy; these are usually not routinely done. Users of the checklist in Port Harcourt, Nigeria, and Yaounde, Cameroon, confirmed that the checklist helped them to counsel patients better.

At the various pause points: just before pushing (or before caesarean), soon after birth, or just before discharge; using the checklist helps to prepare for a safe, positive childbirth experience thus averting morbidity and mortality. Although the childbirth checklist does not introduce any new interventions for safe childbirth; the use reveals when the evidence-based interventions for safe childbirth were not being implemented; partographs not being used, handwashing not being carried out, anticonvulsants not being administered for women with severe preeclampsia, active management of the third stage of labour not being rigorously followed; antibiotics not administered religiously before caesarean sections and skin contact for babies following deliveries not being implemented. These were the experiences we had as users of the checklist in sub-Saharan Africa. All in all; the evidence-based practices for safe childbirth were not being religiously implemented across the obstetric units mostly because of financial constraints and a dearth of human resources. The workforce skills upgrade was the first to improve; however skills alone is not enough to change outcomes; it improved satisfaction with work done; with care received, but with overall morbidity and mortality reduction, the change is not readily visible.

**Author details**

and Rosemary Ogu3, 7\*

Yaounde, Cameroon

Port Harcourt, Nigeria

Ghana

Nigeria

Nigeria

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\*Address all correspondence to: rosemary.ogu@uniport.edu.ng

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2 Department of Community Medicine, University of Port Harcourt Teaching Hospital,

3 Medical Women's Association of Nigeria, Rivers State Branch, Port Harcourt, Nigeria

5 Department of Obstetrics and Gynaecology, Cape Coast Teaching Hospital, Cape Coast,

7 Department of Obstetrics and Gynaecology, University of Port Harcourt, Port Harcourt,

6 Department of Preventive and Social Medicine, University of Port Harcourt, Port Harcourt,

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Julius Dohbit<sup>1</sup>

To enable visible change in maternal and perinatal morbidity and mortality outcomes, users of the checklist must in addition to workforce skills training and coaching, advocate for supplies and commodities availability. When antibiotics, anticonvulsants, oxytocics, antiseptics, water, electricity and safe childbirth checklist are available, effective delivery of services, counselling and respectful maternity care leads to improved maternal and perinatal outcomes.

### **5. Conclusion**

Using the Safe Childbirth Checklist ensures the delivery of essential maternal and perinatal midwifery care practices. The Safe Childbirth Checklist addresses the major causes of maternal deaths, intrapartum-related stillbirths, and neonatal deaths and enables the caregiver to anticipate and avert complications. It also enables the caregiver to acknowledge the limitations/gaps in the currently available health service delivery unit and advocate for supplies and equipment. It has the potential to facilitate compliance with best practices for the delivery of evidence-based better birth. Complications from obstetric haemorrhage, infection, obstructed labour, hypertensive disorders, inadequate intrapartum care, birth asphyxia, infection, and complications related to prematurity can be minimised if the tenets of the checklist are followed. Its use in obstetric units is therefore advocated.

### **Acknowledgements**

The authors thank Pfizer for the Pfizer Independent Grant for Learning and Change (Pfizer IGLC) ID Number 33584051; the World Health Organisation Patient Safety and Quality Improvement Unit, Geneva, Switzerland; Dr Clarissa Fabre & Dr Shelley Ross of Medical Women International Association for their support.

### **Conflict of interest**

The authors declare no conflict of interest.
