Clean Birth Kits- Potential to Deliver?
Evidence, experience, estimated lives saved and Cost
This policy brief summarizes the current state of knowledge on clean birth practices and the potential role for clean birth kits in supporting these preventive practices and for saving lives. Each year an estimated 1 million newborns and mothers will die from infections soon after birth and this burden is highest for the poorest families. An estimated 10% Africa and 12% South Asia of these maternal deaths are estimated to be due to infection, many associated with unhygienic practices around the time of birth. In addition 3.6 million new born die in their first month of life with 26% of these deaths due to serious infections. One third or more of these infection related neonatal deaths are estimated to be caused by unhygienic care at birth and another 2% of newborns die from neonatal tetanus.
An estimated 60 million women each year give birth not in a health facility and 50 million deliver without assistance from a skilled attendant (midwife, nurse or doctor). In Africa just over half of births are at home and of home births, 2/3 have no attendant at all and one third have a traditional birth attendant .In contrast in South Asia almost 2/3 of births take place at home and of these the majority deliver with a TBA.The only region with a significant number of home births attended by skilled attendants is South East Asia. This pattern is driven largely by Indonesia where community midwives are widely available. Although health facilities births are typically cleaner than home births, interventions to improve hygiene at birth are needed in both environments in most low and middle income countries. Progress for skilled attendance at birth has been slow –only 13 of 68 countries have increased coverage by more than 10% since 1990. Of the world’s 60 million home births each year, many occur without adequate hygiene. Some facility births also lack basic hygienic care. Immediate solutions are necessary to address this.
Knowledge about the importance of clean birth has been available for centuries. The practices are often summarized as the Six Cleans. The six cleans include – clean hands, clean perineum, clean delivery surface, clean cord cutting implement, clean cord tying and clean cord care. A few basic commodities are required in order to achieve the 6 cleans: soap, a piece of plastic, a clean blade and clean thread. Unfortunately these commodities are unavailable in many settings or may be too expensive for families to purchase. In other instances these commodities are available but not used; complex behavioural change may be required to ensure birth attendants practise the 6 cleans and to ensure cultural acceptability to women and their families.
Approaches to increase uptake of these clean practices include media and public health messaging, community based behaviour change and training, CBK distribution and facility based training and equipment distribution. Clean Birth Kits are defined as including disposable items for clean birth practices e.g soap, blade, plastic sheet etc.
A systematic review identified 30 studies showing that clean birth practices can substantially reduce neonatal mortality and morbidity from infection –related causes including tetanus. In 3 of the studies (I Randomized Controlled Trial (RCT) , a reduction in maternal sepsis was additionally reported. The evidence supports the role of CBKs in promoting clean birth practices although in all cases there were co-interventions. Conducting RCTs of clean birth practices compared to unclean would be unethical and as a consequence evidence regarding clean birth practices is overall of low quality.
If 90% of all home births applied clean practices (54 million births) then the lives of an estimated 6300 women and 102,000 newborns would be saved each year. Uptake of such practices may be catalyzed by CBKs.The estimated cost of CBKs is between $0.17 and $0.73 per birth, depending on whether made locally or imported. If CBKs are made locally this amounts to a cost of around $ 215 per life saved. Hence although CBKs may avert a comparatively small proportion of all maternal and neonatal deaths as the costs are low, they are highly cost effective interventions for both women and babies and also most likely to benefit the poorest families. The number of lives saved would be greater for facility births since safe as well as clean practices could be provided although the cost would be much higher.
CBKs use is reported in at least 51 countries and in some countries are national policy and widely used. Important research gaps remain, particularly the effect of CBKs on uptake of facility birth and also the effect of varying implementation and distribution strategies. There is an urgent need for more data before birth kits are expanded to include additional commodities.
Safe birth is a basic right for mothers and new borns.Clean birth forms an important part of this right and must be promoted alongside other proven interventions such as universal access to skilled attendance at birth and referral systems strengthening to access emergency obstetric and new born care. Mother held CBKs are highly cost effective and considered appropriate in conflict or humanitarian emergencies or in settings where there is currently low coverage of facility birth as long as they do not act as a disincentive for facility birth.
Credits: Blencowe,H Lawn J,Graham W
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Save the Children and Immpact 2010