Abstract
<title>Abstract</title> <p>Background Maternal and neonatal mortality remain disproportionately high in urban low-income settings, where facility-based care does not always guarantee quality. The WHO Safe Childbirth Checklist (WHO SCC) is an evidence-based tool designed to strengthen adherence to essential birth practices. There is limited evidence on its implementation in health facilities within urban informal settlements in Kenya. Methods An observational implementation study involving a retrospective review of 248 patient records was conducted across 3 health facilities in Ruaraka Sub-County, Nairobi, Kenya, to assess checklist completion, item-level adherence, and predictors across four critical pause points: on admission, before delivery, soon after birth, and before discharge. Findings Cheklist item-level documentation was uniformly low, with no single item exceeding 45.3% completion and most items falling below 40%. Overall coverage was highest at pause points 1 and 2 (means 37.8% and 37.9%) and lowest at pause point 4 (mean 22.4%), representing a 15-percentage-point drop between the first and final pause points-the latter being critical for continuity of care post-partum. More than half of all records showed no documented checklist items at any stage, though mean completion ranged from 22% to 38% driven by a subset of higher-performing records. Steady improvement was observed across three six-month periods, rising from 3% at discharge (Jul-Dec 2024) to a peak of 51% at PP3 (Jul-Dec 2025). Nulliparous women under 25 were more likely to have complete checklists, while women with complications paradoxically received less documentation. A 41-percentage-point gap existed between facilities and time since implementation was the only variable retaining independent significance (OR = 1.12 per month, p = 0.018) meaning each additional month of sustained implementation was associated with a 12% increase in the odds of SCC adherence. Discussion Discharge deficits reflect systemic deprioritization of continuity-of-care actions under high-volume conditions, while the paradox that women with complications received less documentation signals a fundamental misalignment between tool use and the high-risk populations it was designed to protect. Checklist institutionalization is an incremental process in which sustained operational support such as training, designated champions, mentorship, and workflow integration determines whether the tool becomes embedded in routine practice. Conclusion The WHO SCC demonstrated capacity to improve documentation of essential birth practices, with facility-level predictors implementation duration, training volume, and workflow integration as key determinants. Closing the adherence gap, particularly at discharge and for high-risk cases, requires strengthening these predictors through sustained support beyond initial checklist introduction.</p>