In the past decade, India has made great steps forward in health care, reducing maternal mortality by a third and infant mortality by over 40%. Nevertheless, it remains one of the deadliest places in the world to give birth.

As of 2015, India still accounted for 22% of all the world’s stillbirths, and according to the World Bank, 174 Indian mothers die per 100,000 live births. Thirty six Indian newborns die per 1,000 live births. Maternal and infant mortality rates are even worse in rural areas, where the country’s poor struggle with scarce resources and poor infrastructure.

To combat childbirth-related deaths, in November 2014, Ariadne Labs, a Harvard-backed organization focused on childbirth research, started a pilot program to reduce maternal and infant deaths, and stillbirths in India. The program distributed a promising free “technology” that could improve care even the roughest rural health centers: a simple checklist.

The approach was sound and supported by previous smaller-scale research: Following certain basic practices while assisting women in childbirth had been shown to lead to healthier mothers and newborns. The checklist itself seemed like an effective and easy-to-use tool for untrained health care personnel. And yet, things didn’t pan out quite as hoped.

Enter the checklist

The World Health Organization’s Safe Childbirth Checklist, comprising 29 questions and instructions, was designed by a global team of experts to guide caregivers through optimal childbirth practices. Entries ranged from ensuring hand washing and the availability of sanitary supplies (gloves, medications, syringes) to checking for symptoms of emergency conditions.

In use in 30 countries worldwide, the checklist had already been proven effective. Its introduction in a hospital in Namibia, for instance, reduced stillbirth rates (pdf), from 22 deaths per every 1,000 deliveries to 13.8 every 1,000. Each entry in the list had been proven to generate direct improvements in maternal and child harm health; they included key common-sense practices such as immediately referring women with complications to specialized care; instructing the mother to call for help before emergencies escalate; and ensuring gloves are available and hands washed.

And as Atul Gawande, who is the executive director of Ariadne Labs, has demonstrated through his research on the impact of checklists everywhere from aviation to surgery, organizing prompts as a simple, four-page document can help ensure that no step is forgotten.

The BetterBirth project in India would be the largest implementation of the checklist yet, serving 300,000 women in Uttar Pradesh, India’s most populous state and one of the most deadly for new mothers. To track the checklist’s effect, 60 health centers were given the checklist with tutoring about how to use it, and 60 others monitored as control sites without the checklist. The project continued for just over two years, ending in Dec. 2016.

A study of the project, published this week in the New England Journal of Medicine, assessed two outcomes: Whether health center staff kept following the checklist, at two and 12 months after the program began; and whether maternal and child health at delivery improved.

The results were surprising. The better, healthier practices did catch on—health centers adopted an average of 73% of the checklist’s points. Control sites were found to be implementing only 42% of those practices of their own volition. Program director Katherine Semrau describes those rates as dramatic progress in the effort to change unhealthy behaviors—and testimony to the efficacy of the checklist format. But women and children continued to die at the same rates.

No quick fix

How could it be that practices proven to improve health had no effect on maternal or infant mortality rates in India? The likely explanation is simply that good habits alone cannot solve the real problem: An abject lack of means and infrastructure that stops poor women from accessing health care facilities, doctors and education. In short, poverty itself.

Vishwajeet Kumar, the executive director of UP-based Community Empowerment Lab who co-authored the BetterBirth study, says that one of the explanations of the checklist’s lack of impact on death rates is that “within the community health centers, the capabilities of addressing emergencies are limited.” Such centers are very basic health facilities that provide routine services to rural areas, each covering a population of over 250,000 people. Often, these facilities may not have specialized OB-GYNs, blood banks to transfuse hemorrhaging women, or even an operating theatre to perform C-sections.

The checklist shows staff how to refer patients with complications to higher-level facilities (typically district hospitals serving millions people), but getting to those hospitals isn’t easy. Poor women might not have ways to travel to them, they might not be able to afford medical expenses, or the hospitals might be too crowded to accommodate them. In contrast, the checklist’s debut in Namibia had happened in a hospital, which made referrals for more complex care easier.

Often, says Kumar, patients “end up going back to their homes and wait[ing] for the inevitable.” According to Kumar, most pregnant patients only visited the health centers briefly, typically arriving around four hours before birth and leaving only a few hours afterwards. The minimum recommended hospital stay following an uncomplicated vaginal birth is 24 hours.

The benefits of the checklist

Kumar says he observed that the checklist produced healthier babies, with lower rates of infection and disease, and higher infant weight gain, height, and head circumference. However, these metrics were not measured by the BetterBirth study.

The study also did help identify areas of improvement, such as skills training, or offering transportation services. Further, using the checklist helped staff gather data on women who needed referrals to high-level medical intervention—between 5% and 10% of patients.

The sobering finding is that no number of best practices can compensate for sheer lack of resources. But that in itself is valuable information, says Kumar. “The initial focus was to get [the checklist] to the facility, now the focus is to strengthen the system.”