Despite some recent improvements, Zambia continues to experience high maternal and neonatal mortality rates. As of 2014, the maternal mortality ratio was estimated to be 398 per 100,000 live births [
1], far above the average in developing countries of 239 deaths per 100,000 [
2], while the neonatal mortality rate for 2009 to 2013 was 24 deaths per 1000 live births [
1].
Maternal and new-born mortality can be prevented through the provision of basic health services for all women and appropriate emergency obstetric and new-born care (EmONC) services for women and infants who need it [
3]. Although evidence suggests that basic services during pregnancy, at the time of delivery, and post-delivery, can prevent maternal and new born deaths, there are a number of barriers that prevent provision of basic maternity services. For instance, a critical challenge in Zambia and many other countries is that not all women deliver at a health facility and therefore do not have access to skilled health workers at the time of delivery [
1]. A further challenge is that even when mothers go to health facilities, the appropriate staffing and supplies may not always be available to support the provision of essential childbirth services. Specifically, the facility must be staffed by a skilled birth attendant (SBA), which is an accredited health professional such as a midwife, clinical officer, doctor, or other health worker who has been educated and trained to proficiency in the skills needed to manage normal (uncomplicated) pregnancies, childbirth and the immediate postnatal period, and in identification, management and referral of complications in women and new-borns [
4]. An SBA not only needs specific training to be able to provide the EmONC signal functions, but they should also have access to equipment, drugs, supplies, a referral system, and functioning communication and transportation infrastructure. Zambia’s health worker shortages are most acute in rural and remote areas with an estimated 12.4 clinicians per 10,000 persons as compared to 18.7 per 10,000 persons living in urban areas [
5]. Both these ratios fall below the World Health Organization’s recommended threshold of 22.8 clinicians per 10,000 [
6]. Even when mothers attend facilities for deliveries and the appropriate staffing and supplies are available, there remains a final barrier in assuring that the appropriate services are actually provided in a high-quality and comprehensive way. Possible factors associated with poor quality services could be limited health worker knowledge, confidence, and time.
The Safe Childbirth Checklist (SCC), developed by the World Health Organisation (WHO), is one tool that may help to improve the quality and safety of delivery services. The WHO SCC is based on the experience of the Safe Surgical Checklist, which demonstrated significant reductions in surgical complications and deaths [
7]. The SCC consists of reminders to prompt evidenced-based practices that are essential to providing quality care at the time of labour and delivery. The tool is designed for use by birth attendants at four critical “pause points” in the delivery process: (1) at admission, (2) just prior to delivery, (3) in the immediate post-partum period, and (4) prior to discharge. A number of published studies have examined the process and effectiveness of introducing the SCC in specific country contexts, including India [
8‐
13], Sri Lanka [
14], Italy [
15], Iran [
16], and Namibia [
17,
18]. A pilot study in India found that the delivery of evidence-based essential birth practices at each birth event increased from an average of 10 out of 29 practices prior to introduction of the SCC to an average of 25 out of 29 practices after the SCC had been introduced. However, there was no overall effect on mortality [
19].
While the SCC has been implemented in sub-Saharan countries including Namibia and Uganda, the SCC has not previously been implemented in Zambia where maternal mortality is higher [
20,
21]. The Ministry of Health (MOH) is currently considering nation-wide adoption of the SCC, but there is a need for context-specific evidence, specifically evidence about how to successfully implement the SCC, to generate lessons about the roll-out process in Zambia. This study will be unique compared to many previous studies that have investigated SCC adoption because the adoption of the tool will be integrated into a scalable, national framework for mentorship to health facilities.