Using Observational Data to Estimate the Effect of Hand Washing and Clean Delivery Kit Use by Birth Attendants on Maternal Deaths after Home Deliveries in Rural Bangladesh, India and Nepal
Globally, 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...
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| creator | Seward, Nadine Prost, Audrey Copas, Andrew Corbin, Marine Li, Leah Colbourn, Tim Osrin, David Neuman, Melissa Azad, Kishwar Kuddus, Abdul Nair, Nirmala Tripathy, Prasanta Manandhar, Dharma Costello, Anthony Cortina-Borja, Mario |
| description | Globally, 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.
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. 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.
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). 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).
Our 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. |
| doi_str_mv | 10.1371/journal.pone.0136152 |
| format | Article |
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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. 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.
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). 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).
Our 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.</description><identifier>ISSN: 1932-6203</identifier><identifier>EISSN: 1932-6203</identifier><identifier>DOI: 10.1371/journal.pone.0136152</identifier><identifier>PMID: 26295838</identifier><language>eng</language><publisher>United States: Public Library of Science</publisher><subject>Adult ; Bangladesh - epidemiology ; Bias ; Birth ; Births ; Childbirth & labor ; Children & youth ; Childrens health ; Confidence intervals ; Cross-Sectional Studies ; Data processing ; Delivery (Childbirth) ; Delivery, Obstetric - mortality ; Epidemiology ; Estimates ; Fatalities ; Graph theory ; Hand ; Hand Disinfection - trends ; Handwashing ; Health aspects ; Home Childbirth - statistics & numerical data ; Hospitals ; Humans ; Hygiene ; India - epidemiology ; Logistic Models ; Maternal mortality ; Maternal Mortality - trends ; Medical personnel ; Medical research ; Midwifery ; Midwifery - ethics ; Morbidity ; Mortality ; Nepal - epidemiology ; Odds Ratio ; Physiological aspects ; Population ; Practice ; Puerperal Infection - mortality ; Puerperal Infection - prevention & control ; Randomized Controlled Trials as Topic ; Regression analysis ; Regression models ; Rural Population ; Sensitivity analysis ; Sepsis ; Studies ; Survival ; Systematic review ; Washing ; Womens health</subject><ispartof>PloS one, 2015-08, Vol.10 (8), p.e0136152-e0136152</ispartof><rights>COPYRIGHT 2015 Public Library of Science</rights><rights>2015 Seward et al. This is an open access article distributed under the terms of the Creative Commons Attribution License: http://creativecommons.org/licenses/by/4.0/ (the “License”), which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited Notwithstanding the ProQuest Terms and Conditions, you may use this content in accordance with the terms of the License.</rights><rights>2015 Seward et al 2015 Seward et al</rights><lds50>peer_reviewed</lds50><oa>free_for_read</oa><woscitedreferencessubscribed>false</woscitedreferencessubscribed><citedby>FETCH-LOGICAL-c692t-d391353f50591ce5e318aaba8e4609fb8805c819b3d2c8e61e2838e2dc6973403</citedby><cites>FETCH-LOGICAL-c692t-d391353f50591ce5e318aaba8e4609fb8805c819b3d2c8e61e2838e2dc6973403</cites></display><links><openurl>$$Topenurl_article</openurl><openurlfulltext>$$Topenurlfull_article</openurlfulltext><thumbnail>$$Tsyndetics_thumb_exl</thumbnail><linktopdf>$$Uhttps://www.ncbi.nlm.nih.gov/pmc/articles/PMC4546655/pdf/$$EPDF$$P50$$Gpubmedcentral$$Hfree_for_read</linktopdf><linktohtml>$$Uhttps://www.ncbi.nlm.nih.gov/pmc/articles/PMC4546655/$$EHTML$$P50$$Gpubmedcentral$$Hfree_for_read</linktohtml><link.rule.ids>230,314,723,776,780,860,881,2096,2915,23845,27901,27902,53766,53768,79343,79344</link.rule.ids><backlink>$$Uhttps://www.ncbi.nlm.nih.gov/pubmed/26295838$$D View this record in MEDLINE/PubMed$$Hfree_for_read</backlink></links><search><creatorcontrib>Seward, Nadine</creatorcontrib><creatorcontrib>Prost, Audrey</creatorcontrib><creatorcontrib>Copas, Andrew</creatorcontrib><creatorcontrib>Corbin, Marine</creatorcontrib><creatorcontrib>Li, Leah</creatorcontrib><creatorcontrib>Colbourn, Tim</creatorcontrib><creatorcontrib>Osrin, David</creatorcontrib><creatorcontrib>Neuman, Melissa</creatorcontrib><creatorcontrib>Azad, Kishwar</creatorcontrib><creatorcontrib>Kuddus, Abdul</creatorcontrib><creatorcontrib>Nair, Nirmala</creatorcontrib><creatorcontrib>Tripathy, Prasanta</creatorcontrib><creatorcontrib>Manandhar, Dharma</creatorcontrib><creatorcontrib>Costello, Anthony</creatorcontrib><creatorcontrib>Cortina-Borja, Mario</creatorcontrib><title>Using Observational Data to Estimate the Effect of Hand Washing and Clean Delivery Kit Use by Birth Attendants on Maternal Deaths after Home Deliveries in Rural Bangladesh, India and Nepal</title><title>PloS one</title><addtitle>PLoS One</addtitle><description>Globally, 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.
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. 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.
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). 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).
Our 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.</description><subject>Adult</subject><subject>Bangladesh - epidemiology</subject><subject>Bias</subject><subject>Birth</subject><subject>Births</subject><subject>Childbirth & labor</subject><subject>Children & youth</subject><subject>Childrens health</subject><subject>Confidence intervals</subject><subject>Cross-Sectional Studies</subject><subject>Data processing</subject><subject>Delivery (Childbirth)</subject><subject>Delivery, Obstetric - mortality</subject><subject>Epidemiology</subject><subject>Estimates</subject><subject>Fatalities</subject><subject>Graph theory</subject><subject>Hand</subject><subject>Hand Disinfection - trends</subject><subject>Handwashing</subject><subject>Health aspects</subject><subject>Home Childbirth - statistics & numerical data</subject><subject>Hospitals</subject><subject>Humans</subject><subject>Hygiene</subject><subject>India - epidemiology</subject><subject>Logistic Models</subject><subject>Maternal mortality</subject><subject>Maternal Mortality - trends</subject><subject>Medical personnel</subject><subject>Medical research</subject><subject>Midwifery</subject><subject>Midwifery - ethics</subject><subject>Morbidity</subject><subject>Mortality</subject><subject>Nepal - epidemiology</subject><subject>Odds Ratio</subject><subject>Physiological aspects</subject><subject>Population</subject><subject>Practice</subject><subject>Puerperal Infection - mortality</subject><subject>Puerperal Infection - prevention & control</subject><subject>Randomized Controlled Trials as Topic</subject><subject>Regression analysis</subject><subject>Regression models</subject><subject>Rural Population</subject><subject>Sensitivity 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Journals</collection><jtitle>PloS one</jtitle></facets><delivery><delcategory>Remote Search Resource</delcategory><fulltext>fulltext</fulltext></delivery><addata><au>Seward, Nadine</au><au>Prost, Audrey</au><au>Copas, Andrew</au><au>Corbin, Marine</au><au>Li, Leah</au><au>Colbourn, Tim</au><au>Osrin, David</au><au>Neuman, Melissa</au><au>Azad, Kishwar</au><au>Kuddus, Abdul</au><au>Nair, Nirmala</au><au>Tripathy, Prasanta</au><au>Manandhar, Dharma</au><au>Costello, Anthony</au><au>Cortina-Borja, Mario</au><format>journal</format><genre>article</genre><ristype>JOUR</ristype><atitle>Using Observational Data to Estimate the Effect of Hand Washing and Clean Delivery Kit Use by Birth Attendants on Maternal Deaths after Home Deliveries in Rural Bangladesh, India and Nepal</atitle><jtitle>PloS one</jtitle><addtitle>PLoS One</addtitle><date>2015-08-21</date><risdate>2015</risdate><volume>10</volume><issue>8</issue><spage>e0136152</spage><epage>e0136152</epage><pages>e0136152-e0136152</pages><issn>1932-6203</issn><eissn>1932-6203</eissn><abstract>Globally, 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.
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. 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.
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). 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).
Our 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.</abstract><cop>United States</cop><pub>Public Library of Science</pub><pmid>26295838</pmid><doi>10.1371/journal.pone.0136152</doi><oa>free_for_read</oa></addata></record> |
| fulltext | fulltext |
| identifier | ISSN: 1932-6203 |
| ispartof | PloS one, 2015-08, Vol.10 (8), p.e0136152-e0136152 |
| issn | 1932-6203 1932-6203 |
| language | eng |
| recordid | cdi_plos_journals_1708482686 |
| source | PLoS (Open access); MEDLINE; Full-Text Journals in Chemistry (Open access); DOAJ Directory of Open Access Journals; PubMed Central; EZB Electronic Journals Library |
| subjects | Adult Bangladesh - epidemiology Bias Birth Births Childbirth & labor Children & youth Childrens health Confidence intervals Cross-Sectional Studies Data processing Delivery (Childbirth) Delivery, Obstetric - mortality Epidemiology Estimates Fatalities Graph theory Hand Hand Disinfection - trends Handwashing Health aspects Home Childbirth - statistics & numerical data Hospitals Humans Hygiene India - epidemiology Logistic Models Maternal mortality Maternal Mortality - trends Medical personnel Medical research Midwifery Midwifery - ethics Morbidity Mortality Nepal - epidemiology Odds Ratio Physiological aspects Population Practice Puerperal Infection - mortality Puerperal Infection - prevention & control Randomized Controlled Trials as Topic Regression analysis Regression models Rural Population Sensitivity analysis Sepsis Studies Survival Systematic review Washing Womens health |
| title | Using Observational Data to Estimate the Effect of Hand Washing and Clean Delivery Kit Use by Birth Attendants on Maternal Deaths after Home Deliveries in Rural Bangladesh, India and Nepal |
| url | https://sfx.bib-bvb.de/sfx_tum?ctx_ver=Z39.88-2004&ctx_enc=info:ofi/enc:UTF-8&ctx_tim=2025-02-01T11%3A56%3A36IST&url_ver=Z39.88-2004&url_ctx_fmt=infofi/fmt:kev:mtx:ctx&rfr_id=info:sid/primo.exlibrisgroup.com:primo3-Article-gale_plos_&rft_val_fmt=info:ofi/fmt:kev:mtx:journal&rft.genre=article&rft.atitle=Using%20Observational%20Data%20to%20Estimate%20the%20Effect%20of%20Hand%20Washing%20and%20Clean%20Delivery%20Kit%20Use%20by%20Birth%20Attendants%20on%20Maternal%20Deaths%20after%20Home%20Deliveries%20in%20Rural%20Bangladesh,%20India%20and%20Nepal&rft.jtitle=PloS%20one&rft.au=Seward,%20Nadine&rft.date=2015-08-21&rft.volume=10&rft.issue=8&rft.spage=e0136152&rft.epage=e0136152&rft.pages=e0136152-e0136152&rft.issn=1932-6203&rft.eissn=1932-6203&rft_id=info:doi/10.1371/journal.pone.0136152&rft_dat=%3Cgale_plos_%3EA426228352%3C/gale_plos_%3E%3Curl%3E%3C/url%3E&disable_directlink=true&sfx.directlink=off&sfx.report_link=0&rft_id=info:oai/&rft_pqid=1708482686&rft_id=info:pmid/26295838&rft_galeid=A426228352&rft_doaj_id=oai_doaj_org_article_0dfe67b0954f4a1187bba632945d1362&rfr_iscdi=true |