Barriers and facilitators for implementing the WHO Safe Childbirth Checklist (SCC) in Mozambique: A qualitative study using the Consolidated Framework for Implementation Research (CFIR)

Abstract

High maternal and neonatal mortality rates persist in Mozambique, with stillbirths remaining understudied. Most maternal and neonatal deaths in the country are due to preventable and treatable childbirth-related complications that often occur in low-resource settings. The World Health Organization introduced the Safe Childbirth Checklist (SCC) in 2015 to reduce adverse birth outcomes. The SCC, a structured list of evidence-based practices, targets the main causes of maternal and neonatal deaths and stillbirths in healthcare facilities. The SCC has been tested in over 35 countries, demonstrating its ability to improve the quality of care. However, it has not been adopted in Mozambique. This study aimed to identify potential facilitators and barriers to SCC implementation from the perspective of birth attendants, clinical administrators, and decision-makers to inform future SCC implementation in Mozambique. We conducted a qualitative study involving focus group discussions with birth attendants (n = 24) and individual interviews with clinical administrators (n = 6) and decision-makers (n = 8). The Consolidated Framework for Implementation Research guided the questions used in the interviews and focus group discussions, as well as the subsequent data analysis. A deductive thematic analysis of Portuguese-to-English translated transcripts was performed. In Mozambique, most barriers to potential SCC implementation stem from the challenges within a weak health system, including underfunded maternal care, lack of infrastructure and human resources, and low provider motivation. The simplicity of the SCC and the commitment of healthcare providers to better childbirth practices, combined with their willingness to adopt the SCC, were identified as major facilitators. To improve the feasibility of SCC implementation and increase compatibility with current childbirth routines for birth attendants, the SCC should be tailored to context-specific needs. Future research should prioritize conducting pre-implementation assessments to align the SCC more effectively with local contexts and facilitate sustainable enhancements in childbirth practices.