The key points: Poor quality of care at childbirth has been recognized globally as a major contributor to high rates of death for mothers and babies in childbirth. 1/12
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WHO’s Safe Childbirth Checklist was designed to help birth attendants & managers better insure women receive essential care for the biggest killers, eg washing hands + using clean gloves to prevent infections; monitoring and treating BP to stop eclampsia. 2/12
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We found coaching attendants and managers in rural clinics across Uttar Pradesh, India, to use the checklist to recognize and address gaps in practices, resources, and organization lifted them in 2 months from delivering 42% to 73% of essential safe practices. 3/12
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On the one hand, this was remarkable, rapid change at such large scale. On the other hand, it wasn’t enough to reduce stillbirths, perinatal mortality, or maternal mortality/morbidity. 4/12
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So what to make of this? A few important lessons: - Large scale improvement IS possible even in tough, resource-limited settings. - It required changes not just in bedside practices but also in mgmt practices. - The plan was good but did not produce sufficient change. 5/12
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What more is needed? We and others will test the question now. Possibilities: A. We should have stayed longer than 8 months. Our other large studies (eg in surgery) are showing 3 years or longer to produce large scale, sustainable change in outcomes.
@AriadneLabs 6/12Show this thread -
B. Managers and district leaders need stronger forms of accountability for quality improvement. 7/12
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C. We should implement supply and skill upgrades before implementing checklists/coaching. 8/12
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D. The NEJM editorial argues rural clinics are inherently too limited and deliveries need hospitals with surgical and other capabilities. http://www.nejm.org/doi/full/10.1056/NEJMe1713831 … 9/12
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Bottom line:
#BetterBirth was the most ambitious, difficult, and important effort I’ve ever been part of. It has provided deeper, more profound information than we’ve ever had about how we make progress in saving women and babies’ lives. 11/12Show this thread -
I could not be prouder of anything I’ve ever undertaken.
@k_semrau@Vishwajeet_CEL@WHO@PSIimpact@AriadneLabs#BetterBirth 12/12Show this thread
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Congratulations. I have found every evaluation of a large program we have done humbling and a lesson in collaboration. And more. Did you do any ethnographic research too? It’s great for behavioural insights. (Haven’t read the paper yet). Congrats
@Vishwajeet_CEL too. -
Disappointed by the nature of understanding of "Complexity" and its relation to Impact in this study . A Complex Adaptive system has "Emergences" . The First emergence crucial here is seen in better "essential birth practices" .The nature of pedagogy followed is also critical.
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2. It is incorrect to end with a statement that "we currently lack a complete understanding of the complex interaction among quality of care, context, and outcomes" We never will, completely as a) Complex systems do not become Smaller simple systems.b)the unit is the individual..
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c) Coaching is not a pedagogy for CAS..as Coaching foresees a linear trajectory of improvement which is in fundamental conflict with Complexity. Learning through game is.
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Most importantly..Every health policy shouldn't be implemented just because it is intuitive, must be subject to large RCTs before being implemented at scale, to prevent wastage of resources
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Not every field is same, a procedure/homogenous disease with well defined inclusion criteria will performs well with checklists than others..
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Why no reduction in maternal or perinatal mortality or maternal morbidity?
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Congratulations to
@Atul_Gawande and@WHO team for your efforts to improve LIFE!#BetterBirthThanks. Twitter will use this to make your timeline better. UndoUndo
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