The WHO Safe Childbirth Checklist was introduced in 60 facilities in Uttar Pradesh, India along with an eight-month coaching program. Previous evaluations had found that the checklist improved the planning and performance of 28 essential birth practices, and a matched-pair, cluster-randomized, controlled trial was designed to evaluate the impact of the checklist and coaching intervention – called the BetterBirth program – on maternal and perinatal outcomes within seven days of delivery.¹ There were three tiers of mentors and trainers within the intervention: childbirth quality coordinators, coaches, and coach team leaders. Childbirth quality coordinators were selected at each facility. Coaches visited facilities to help identify and solve barriers related to use of the checklist, and coach team leaders accompanied coaches on every other visit to help support communication and identification of resource gaps and solutions. During the trial, birth attendants adhered to 72.8% of the 18 childbirth practices in the intervention sites compared to 41.7% in the control sites at two months, and although this adherence diminished after the program ceased, it was still significantly higher in intervention facilities. However, there was no significant difference in maternal or perinatal outcomes between the two groups. The authors suggested that the conclusions from this trial were likely contextual. The practices within the Safe Childbirth Checklist all have substantial evidence of impact individually. However, even the increased level of adherence observed in the intervention facilities may not have been sufficient to improve outcomes. The relevance of these findings for implementation of tool-based interventions are twofold. First, increasing adherence to practices through the use of tools may be more effective when implemented in tandem with facility-based coaching. Second, increased adherence to safe or health-promoting practices may not be sufficient to improve health outcomes; it is important to explore contextual factors such as social determinants and health promoting behavior outside of the facility. It is also important that health care workers have a sufficient level of base training knowledge and skills practices before such tools are implemented.