Examining Implementation Patterns of the WHO Safe Childbirth Checklist in Urban Informal Settings: A case study of 3 Health Facilities in Kenya

The Safety Net That Sometimes Has Holes

Imagine you are a doctor in a busy hospital. You have a checklist, like the one pilots use before takeoff, to make sure you don't forget the most important steps to keep a mother and her new baby safe. This isn't just a piece of paper; it's a safety net designed to catch the things that go wrong, like bleeding or high blood pressure, before they become disasters. In the world of public health, this tool is called the WHO Safe Childbirth Checklist. It's built on the idea that if doctors and nurses pause at four critical moments—when the mom arrives, right before the baby is born, immediately after, and right before they leave the hospital—they can save lives.

But here's the tricky part: having a checklist is easy. Actually using it, filling out every box, and sticking to it when you are tired, overwhelmed, or dealing with a crisis is a whole different story. This is the puzzle researchers in Kenya wanted to solve. They asked: "If we give these safety nets to hospitals in crowded, low-income neighborhoods, do people actually use them? And if they do, does it work the same way for everyone?" It's a question that matters because millions of babies and mothers still face dangerous risks during birth, and we need to know if our best tools are actually being used or if they are just gathering dust on a shelf.

The Checklist Adventure in Nairobi's Informal Settlements

In this study, a team of researchers took a close look at three different health facilities in Ruaraka, a bustling area in Nairobi, Kenya, where many people live in informal settlements. They acted like detectives, digging through 248 patient records from the past few years to see how well the "Safety Net" (the WHO Safe Childbirth Checklist) was being used. They weren't just checking if the checklist existed; they were checking if the doctors and nurses actually wrote down the answers to the 29 important questions on it.

The Big Discovery: The "All-or-Nothing" Pattern
The researchers found that the safety net had some very big holes. Overall, the checklist wasn't being used very much. In fact, for more than half of the records they looked at, the checklist was completely blank—zero items checked off. Even when it was used, the completion rate was low; no single item on the list was checked more than 45.3% of the time.

It was like a game where you have to collect 29 coins to win, but most players only managed to grab a few, and many didn't grab any at all. The researchers noticed a strange trend: the checklist was used a bit more often when the mom first arrived (Pause Point 1) and right before the baby was born (Pause Point 2). But as time went on, the usage dropped off a cliff. By the time the mother was ready to go home (Pause Point 4), the checklist was almost completely ignored. The completion rate at discharge was only 22.4%, a massive drop from the start. This means that the most important advice for keeping the baby and mom safe after they leave the hospital—like warning signs to watch for or family planning—was often never written down or discussed.

The Paradox: Who Gets the Safety Net?
Here is where the story gets a little weird. You might think that if a mother is in trouble—maybe she has high blood pressure or is bleeding heavily—the doctors would be extra careful and fill out the checklist perfectly. But the study found the opposite. Women who had complications were less likely to have a completed checklist than women who were doing fine.

The authors suggest this happens because when a doctor is in the middle of a medical emergency, they are so focused on saving the life that they forget to write things down. It's like a firefighter putting out a blaze; they are too busy fighting the fire to fill out the incident report. This creates a dangerous gap: the people who need the safety net the most are the ones least likely to have it.

The Secret Sauce: Time and Technology
So, what made the difference between the hospitals? The researchers found that the most successful hospital (Facility 2) had been using the checklist since 2018, had trained 21 staff members, had a dedicated "champion" to keep everyone on track, and, crucially, had the checklist built into their computer system (Electronic Medical Record). This hospital had a completion rate of 62.4%.

In contrast, the hospital that started the checklist most recently (in 2025) and had no ongoing support or computer integration struggled, with a completion rate of only 21.2%. The study showed that the longer a facility stuck with the checklist and supported their staff, the better they got. For every month the checklist was in place, the odds of it being used correctly went up by 12%. It wasn't magic; it was just practice and support. The study also found that when the checklist was part of the computer system doctors used every day, completion jumped to between 86% and 100%. When it was just a paper form, it often ended up ignored.

What the Study Says It's NOT
The researchers were careful to point out what they didn't find. They didn't find that the checklist itself was too hard to understand; the staff said it was "easy" or "very easy" to use. The problem wasn't the tool; it was the system around it. They also didn't find that the checklist magically stopped all deaths in this specific group (though they noted that one baby died and no mothers died in their small sample), because the study was about how well the checklist was used, not a test of whether it saved lives in this specific group. They also noted that the study was limited to just three facilities, so we can't say for sure if this is exactly what happens in every single hospital in Kenya, but it gives a very strong clue.

The Bottom Line
The study concludes that the WHO Safe Childbirth Checklist is a powerful tool, but it's not a "set it and forget it" solution. It needs a team, time, and the right technology to work. If you just hand a checklist to a busy doctor without training, support, or a way to integrate it into their daily work, it will likely end up blank. The biggest lesson? To keep moms and babies safe, we need to stop treating the checklist as a one-time event and start treating it as a habit that grows stronger with every passing month.