Abstract
BackgroundGlobally, puerperal sepsis accounts for an estimated 8–12% of maternal deaths, but evidence is lacking on the extent to which clean delivery practices could improve maternal survival. We used data from the control arms of four cluster-randomised controlled trials conducted in rural India, Bangladesh and Nepal, to examine associations between clean delivery kit use and hand washing by the birth attendant with maternal mortality among home deliveries.MethodsWe tested associations between clean delivery practices and maternal deaths, using a pooled dataset for 40,602 home births across sites in the three countries. Cross-sectional data were analysed by fitting logistic regression models with and without multiple imputation, and confounders were selected a priori using causal directed acyclic graphs. The robustness of estimates was investigated through sensitivity analyses.ResultsHand washing was associated with a 49% reduction in the odds of maternal mortality after adjusting for confounding factors (adjusted odds ratio (AOR) 0.51, 95% CI 0.28–0.93). The sensitivity analysis testing the missing at random assumption for the multiple imputation, as well as the sensitivity analysis accounting for possible misclassification bias in the use of clean delivery practices, indicated that the association between hand washing and maternal death had been over estimated. Clean delivery kit use was not associated with a maternal death (AOR 1.26, 95% CI 0.62–2.56).ConclusionsOur evidence suggests that hand washing in delivery is critical for maternal survival among home deliveries in rural South Asia, although the exact magnitude of this effect is uncertain due to inherent biases associated with observational data from low resource settings. Our findings indicating kit use does not improve maternal survival, suggests that the soap is not being used in all instances that kit use is being reported.
Highlights
Puerperal sepsis accounts for an estimated 8–12% of maternal deaths, but evidence is lacking on the extent to which clean delivery practices could improve maternal survival
Hand washing was associated with a 49% reduction in the odds of maternal mortality after adjusting for confounding factors (adjusted odds ratio (AOR) 0.51, 95% CI 0.28–0.93)
Our evidence suggests that hand washing in delivery is critical for maternal survival among home deliveries in rural South Asia, the exact magnitude of this effect is uncertain due to inherent biases associated with observational data from low resource settings
Summary
We tested associations between clean delivery practices and maternal deaths, using a pooled dataset for 40,602 home births across sites in the three countries. Analyses were performed as follows: first, logistic regression models were fitted to the pooled data to examine the association of individual clean delivery practices with maternal death, controlling for confounders available at all sites to ensure comparability of results. A likelihood ratio statistic comparing fully adjusted models with the interaction term to similar models without the interaction term, confirmed the appropriateness of pooling data from the three study sites for the exposure of hand washing (p = 0.771) as well as kit use (p = 0.121) These analyses were repeated separately for the three study sites. The adjusted models estimating the effect of hand washing on maternal mortality experienced convergence problems when using the data from the Nepal site as well as the pooled dataset This was mainly due to the small number of mothers who died after delivery, low uptake of skilled birth attendants, and large numbers of missing data on kit use in Nepal. Results indicated no differences, when comparing adjusted models with skilled attendant and kit use (AOR, 0.45, 95% CI: 0.24–0.87) to adjusted models without skilled attendant and Factors associated with hand washing
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