title: Association between clean delivery kit use, clean delivery practices, and neonatal survival: pooled analysis of data from three sites in South Asia.
abstract: BACKGROUND
  Sepsis accounts for up to 15% of an estimated 3.3 million annual neonatal deaths globally. We used data collected from the control arms of three previously conducted cluster-randomised controlled trials in rural Bangladesh, India, and Nepal to examine the association between clean delivery kit use or clean delivery practices and neonatal mortality among home births.
  
  
  RESULTS
  Hierarchical, logistic regression models were used to explore the association between neonatal mortality and clean delivery kit use or clean delivery practices in 19,754 home births, controlling for confounders common to all study sites. We tested the association between kit use and neonatal mortality using a pooled dataset from all three sites and separately for each site. We then examined the association between individual clean delivery practices addressed in the contents of the kit (boiled blade and thread, plastic sheet, gloves, hand washing, and appropriate cord care) and neonatal mortality. Finally, we examined the combined association between mortality and four specific clean delivery practices (boiled blade and thread, hand washing, and plastic sheet). Using the pooled dataset, we found that kit use was associated with a relative reduction in neonatal mortality (adjusted odds ratio 0.52, 95% CI 0.39-0.68). While use of a clean delivery kit was not always accompanied by clean delivery practices, using a plastic sheet during delivery, a boiled blade to cut the cord, a boiled thread to tie the cord, and antiseptic to clean the umbilicus were each significantly associated with relative reductions in mortality, independently of kit use. Each additional clean delivery practice used was associated with a 16% relative reduction in neonatal mortality (odds ratio 0.84, 95% CI 0.77-0.92).
  
  
  CONCLUSIONS
  The appropriate use of a clean delivery kit or clean delivery practices is associated with relative reductions in neonatal mortality among home births in underserved, rural populations.
authors.affiliation: UCL, Centre for International Health and Development, Institute of Child Health, United Kingdom. n.seward@ich.ucl.ac.uk
authors.forename: Nadine
authors.initials: N
authors.lastname: Seward
authors.forename: David
authors.initials: D
authors.lastname: Osrin
authors.forename: Leah
authors.initials: L
authors.lastname: Li
authors.forename: Anthony
authors.initials: A
authors.lastname: Costello
authors.forename: Anni-Maria
authors.initials: AM
authors.lastname: Pulkki-Brännström
authors.forename: Tanja A J
authors.initials: TA
authors.lastname: Houweling
authors.forename: Joanna
authors.initials: J
authors.lastname: Morrison
authors.forename: Nirmala
authors.initials: N
authors.lastname: Nair
authors.forename: Prasanta
authors.initials: P
authors.lastname: Tripathy
authors.forename: Kishwar
authors.initials: K
authors.lastname: Azad
authors.forename: Dharma
authors.initials: D
authors.lastname: Manandhar
authors.forename: Audrey
authors.initials: A
authors.lastname: Prost
mesh_terms: D001459:Bangladesh / Q000453:epidemiology; D016000:Cluster Analysis; D036861:Delivery, Obstetric; D005260:Female; D007722:Health Knowledge, Attitudes, Practice; D006700:Home Childbirth / Q000295:instrumentation* / Q000379:methods / Q000592:standards; D006801:Humans; D007194:India / Q000453:epidemiology; D007226:Infant Mortality; D007231:Infant, Newborn; D008880:Midwifery / Q000295:instrumentation* / Q000379:methods / Q000592:standards; D009390:Nepal / Q000453:epidemiology; D011247:Pregnancy; D012424:Rural Population; D018805:Sepsis / Q000453:epidemiology / Q000401:mortality / Q000517:prevention & control*