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.
abstract: BACKGROUND
  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.
  
  
  METHODS
  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.
  
  
  RESULTS
  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).
  
  
  CONCLUSIONS
  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.
authors: UCL Institute for Global Health, London, United Kingdom.
authors: Nadine
authors: N
authors: Seward
authors: UCL Institute for Global Health, London, United Kingdom.
authors: Audrey
authors: A
authors: Prost
authors: Centre for Sexual Health and HIV Research, UCL Institute of Epidemiology and Health Care, London, United Kingdom.
authors: Andrew
authors: A
authors: Copas
authors: Centre for Public Health Research, Massey University, Wellington, New Zealand; Department of Medical Sciences, Cancer Epidemiology Unit, CeRMS and CPO-Piemonte, University of Turin, Turin, Italy.
authors: Marine
authors: M
authors: Corbin
authors: Population, Policy and Practice Programme, UCL Institute of Child Health, London, United Kingdom.
authors: Leah
authors: L
authors: Li
authors: UCL Institute for Global Health, London, United Kingdom.
authors: Tim
authors: T
authors: Colbourn
authors: UCL Institute for Global Health, London, United Kingdom.
authors: David
authors: D
authors: Osrin
authors: UCL Institute for Global Health, London, United Kingdom.
authors: Melissa
authors: M
authors: Neuman
authors: Perinatal Care Project (PCP), Dhaka, Bangladesh.
authors: Kishwar
authors: K
authors: Azad
authors: Perinatal Care Project (PCP), Dhaka, Bangladesh.
authors: Abdul
authors: A
authors: Kuddus
authors: Ekjut, Chakradharpur, Jharkhand, India.
authors: Nirmala
authors: N
authors: Nair
authors: Ekjut, Chakradharpur, Jharkhand, India.
authors: Prasanta
authors: P
authors: Tripathy
authors: Mother and Infant Research Activities (MIRA), Kathmandu, Nepal.
authors: Dharma
authors: D
authors: Manandhar
authors: UCL Institute for Global Health, London, United Kingdom.
authors: Anthony
authors: A
authors: Costello
authors: Population, Policy and Practice Programme, UCL Institute of Child Health, London, United Kingdom.
authors: Mario
authors: M
authors: Cortina-Borja
mesh_terms: D000328:Adult; D001459:Bangladesh / Q000453:epidemiology; D003430:Cross-Sectional Studies; D036861:Delivery, Obstetric / Q000401:mortality*; D006235:Hand Disinfection / Q000639:trends*; D006700:Home Childbirth / Q000706:statistics & numerical data; D006801:Humans; D007194:India / Q000453:epidemiology; D016015:Logistic Models; D008428:Maternal Mortality / Q000639:trends*; D008880:Midwifery / Q000941:ethics*; D009390:Nepal / Q000453:epidemiology; D016017:Odds Ratio; D011645:Puerperal Infection / Q000401:mortality* / Q000517:prevention & control; D016032:Randomized Controlled Trials as Topic; D012424:Rural Population