Seward, NEJ; (2015) Clean delivery practices during home deliveries in rural South Asia: effects on maternal and neonatal mortality and interventions aimed at improved use. Doctoral thesis , UCL (University College London).

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Abstract

Background: Globally, puerperal and neonatal sepsis account for an estimated 8-12% and 23% of maternal and neonatal deaths respectively. Clean delivery practices are known to help prevent sepsis, but evidence is lacking on the extent to which they can improve survival following home deliveries in rural communities in low-resource countries. Evidence is also lacking on effective methods to increase the use of different clean delivery practices in these settings. To address these issues, I sought to: (1) determine the associations between clean delivery practices and neonatal and maternal mortality for home deliveries in rural South Asia; (2) review the literature on effective means to promote the use of clean delivery practices; and (3) to determine the effectiveness of community mobilisation through women’s groups in promoting the use of clean delivery practices during home deliveries in rural South Asia. / Methods: I used data from four cluster-randomised controlled trials conducted in rural India, Bangladesh and Nepal. Each of these trials had the primary objective of evaluating the effect of a community mobilisation intervention through participatory women’s groups on neonatal survival. Using pooled datasets from the control arms of these trials, I tested associations between clean delivery practices and neonatal and maternal survival. I also investigated the robustness of the estimates through sensitivity analyses. To assess the effectiveness of community mobilisation in improving the uptake of clean delivery practices, I conducted a meta-analysis using individual patient data from the control and intervention arms of the four previously mentioned trials. / Results: The use of all clean delivery practices, except wearing gloves, was associated with a reduction in neonatal mortality. Hand washing was the only clean delivery practice associated with a reduction in maternal mortality. Sensitivity analyses raised some doubt as to the extent to which clean delivery practices improved neonatal and maternal survival. Analyses of the effect of community mobilisation through women’s groups on the use of clean delivery practices suggested that this was an effective approach to improve their use, especially in the most disadvantaged populations. / Conclusions: The use of clean delivery practices for home births has the potential of saving thousands of unnecessary deaths due to unhygienic conditions during delivery. Given that a substantial proportion of all deliveries in low and middle-income settings are still likely to occur at home, the use of clean delivery practices should be promoted through community interventions in a context appropriate manner. Community mobilisation through women’s groups may be an effective means of promoting the use of such practices, especially among the most vulnerable mothers.

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