Clean birth and postnatal care practices to reduce neonatal deaths from sepsis and tetanus: a systematic review and Delphi estimation of mortality effect

Abstract

Background: Annually over 520,000 newborns die from neonatal sepsis, and 60,000 more from tetanus. Estimates of the effect of clean birth and postnatal care practices are required for evidence-based program planning.

Objective: To review the evidence for clean birth and postnatal care practices and estimate the effect on neonatal mortality from sepsis and tetanus for the Lives Saved Tool (LiST).

Methods: We conducted a systematic review of multiple databases. Data were abstracted into standard tables and assessed by GRADE criteria. Where appropriate, meta-analyses were undertaken. For interventions with low quality evidence but a strong GRADE recommendation, a Delphi process was conducted.

Results: Low quality evidence supports a reduction in all-cause neonatal mortality (19% (95% c.i. 1-34%)), cord infection (30% (95% c.i. 20-39%)) and neonatal tetanus (49% (95% c.i. 35-62%)) with birth attendant handwashing. Very low quality evidence supports a reduction in neonatal tetanus mortality with a clean birth surface (93% (95% c.i. 77-100%)) and no relationship between a clean perineum and tetanus. Low quality evidence supports a reduction of neonatal tetanus with facility birth (68% (95% c.i. 47-88%). No relationship was found between birth place and cord infections or sepsis mortality. For postnatal clean practices, all-cause mortality is reduced with chlorhexidine cord applications in the first 24 hours of life (34% (95% c.i. 5-54%, moderate quality evidence) and antimicrobial cord applications (63% (95% c.i. 41-86%, low quality evidence). One study of postnatal maternal handwashing reported reductions in all-cause mortality (44% (95% c.i. 18-62%)) and cord infection ((24% (95% c.i. 5-40%)).Given the low quality of evidence, a Delphi expert opinion process was undertaken. Thirty experts reached consensus regarding reduction of neonatal sepsis deaths by clean birth practices at home (15% (IQR 10-20)) or in a facility (27% IQR 24-36)), and by clean postnatal care practices (40% (IQR 25-50)). The panel estimated that neonatal tetanus mortality was reduced by clean birth practices at home (30% (IQR(20-30)), or in a facility (38% (IQR 34-40)), and by clean postnatal care practices (40% (IQR 30-50)).

Conclusion: According to expert opinion, clean birth and particularly postnatal care practices are effective in reducing neonatal mortality from sepsis and tetanus. Further research is required regarding optimal implementation strategies.

Figure 1

Conceptual framework of potential role of implementation mechanisms, including kits on clean practices at birth and effects on neonatal and maternal outcomes

Figure 2

Search strategy and results

Figure 3

Meta-analysis of neonatal tetanus variation with facility birth compared to non-facility birth controlling for major confounders (maternal education, tetanus toxoid immunization, care knowledge/ practices)

Figure 4

Meta-analysis of the effect of birth attendant hand washing before birth: 4a) On neonatal tetanus 4b) On cord infection

Figure 5

Meta-analysis of the effect of antimicrobial applications (antibiotics or disinfectants) to cord on neonatal tetanus