Bill & Melinda Gates Foundation

Making Childbirth Safer: It Takes a Sales Force

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January 12, 2015

“The mother and her newborn are safe in my hands!” Ishrawati, a birth attendant at a remote health center in northern India, is feeling confident, and in many ways that’s surprising.

Like millions of mostly female health workers delivering babies in the world’s poorest communities, Ishrawati works under conditions of chronic scarcity. No heating in her facility during freezing winters; no air conditioning in the sweltering summers. No running water in the delivery room much of the time. Outmoded equipment and regular stock outs of medicines. Severe understaffing combined with patchy supervision.

The result: a preventable tragedy where a woman still dies every two minutes from causes related to pregnancy or childbirth and 2.9 million infants don’t survive their first month of life.

If Ishrawati is nonetheless gaining confidence under these daunting circumstances, it’s at least partly because of the coaching she’s received as a participant in the BetterBirth Program. It’s a pioneering research program we’re conducting in 120 public health facilities across rural districts of Uttar Pradesh, one of India’s most disadvantaged states. The stakes are high - if we are successful, it could be
a game changer for maternal and newborn survival worldwide.

Our BetterBirth trial has adopted the WHO Safe Childbirth Checklist as its basic protocol, since it focuses on key lifesaving practices that cannot be forgotten or skipped from the moment a woman arrives in labor until she leaves for home with her newborn baby. In practice, this requires the delivery team to briefly pause in the flow of care and confirm they have taken basic steps, such as washing their hands with soap, taking the mother’s blood pressure, keeping mom and baby in skin to skin contact after birth to maintain the newborn’s body temperature, and so on.


The WHO Safe Childbirth Checklist focuses on improving care at four moments when mother and baby are in greatest danger.  Source: Ariadne Labs


It’s hard to follow a checklist, we knew going into the trial, because it involves both individual and systemic behavior change. There are barriers to overcome to execute even the simplest step, and those barriers differ from place to place. Staff may not wash hands in one place because they don’t know it’s important; in another, because they don’t have sinks or running water in the delivery rooms; and in another, because they simply have not made it their habit and no one cares.

Our observation—and our gamble—is that the last phrase is the critical one: if no one cares when someone takes the trouble to do things right, nothing changes. And the overwhelming message to the people who work at the frontlines of care around the world is that no one notices excellence and no one cares. Burnout and discouragement among health care workers around the world is high.

Our BetterBirth trial is tackling these challenges head on in facilities such as Ishrawati’s. Classroom training won’t solve these problems, we realized. So we're training peers—nurses and doctors—to work onsite with birth attendants and hospital leaders to introduce the checklist and simple metrics of adherence to good practice and to coach them in using these aids to gradually close gaps in care.

These systematic efforts and a granular focus on daily problem solving are beginning to bear fruit.  Though it’s early days, we’ve begun to see changes in childbirth practices in the pilot facilities where we are working. In one facility, the nurses figured out to ask the sweepers to bring a fresh basin of water and soap when they clean the room. In another, the medical-officer-in-charge recognized that he could order an alcohol hand sanitizer.

Use of technologies are essential to good outcomes, from oxytocin injections to stop maternal hemorrhage after delivery to baby masks for resuscitating newborns. Indian government leadership is also making a crucial difference, aided by our committed partners.


The BetterBirth trial involves a major data collection effort in rural Uttar Pradesh. These data collectors gather information on birth outcomes in call centers and community settings. Source: PSI/Ariadne Labs


In the end, though, we think it’s coaching done with empathy that is the true killer app catalyzing improved safe childbirth practices in the over-burdened health centers of Uttar Pradesh. Because the technologies are often unstocked, unused, or wrongly deployed, and it’s only the people on the ground who can change that. Human beings talking to human beings is still how the world’s standards change.

Can this approach succeed at large scale? We’re finding out. Scaling up requires training people who can be a sales force for these concepts and strengthen the connections between the different levels of the health system.

We will report on the findings of the Better Birth trial as they emerge. With
quality of care rising as a global health priority, we are eager to learn from Ishrawati and her nurse midwife colleagues as they model that essential agenda.

We invite you to comment below and share this post on Twitter with a message such as this one: Saving #everynewborn: it takes a sales force

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