Clean Birth Kits: the journey continues

The Clean Birth Kit (CBK) Working Group held its summative meeting, 13 January, at Save the Children headquarters. The event was well attended—in person or virtually—with representation from Save, Immpact (University of Aberdeen), the Maternal Health Taskforce, Family Care International, the Gates Foundation, Georgetown University, Harvard School of Public Health, JHU, PATH, Pathfinder, UNFPA and USAID.

The key take home message from the meeting was “there is more work to do.”

Working groups reported out on activities undertaken since the last meeting in August as part of the year-long effort to assess and advance the evidence-base for birth kits.  These included:

1. Updates on the CBK implementation survey

While the response to the survey (n 17) was disappointing, findings suggest that the introduction and use of kits does not act as a disincentive to facility births. When asked, “Can CBKs be used to promote facility deliveries?” the majority of responders said, “yes.”

“CBKs used in facility can provide a cleaner, safer and sterilized platform for conducting deliveries by simply alternating harmful practices with safer ones with minimized interference in local behaviors and beliefs.”  (Pakistan)

“Though facility based deliveries are on rise, quality of care is questionable due to higher load at the facilities. BKs thus become an important technology to promote for improving quality of care for home and facility deliveries.” (India)

Nearly half of respondents said that in their countries there are government policies regarding the use of CBKs and, in most country programs identified by the survey, CBKs are distributed through government programs—often at antenatal care visits. Thus CBKs are only one element in a larger safe motherhood/newborn effort.

When asked which ONE product would they recommend be included in a kit to increase the public health value for mothers, respondents answered, “misoprostol.” For newborns, “bednets.”

2. Report out from the CBK evidence-based “add-ons” review

This working group continued its examination of the effectiveness of add-on commodities to a standard clean delivery kit for facility- or home-based care. Based on extant evidence, the sub-committee recommends as “standard,” inclusion of soap, cord clamp and tie, blade, clean sheet, and pictorial instruction leaflet. An extended systematic review was undertaken of the 5 candidate add-ons identified in the initial evidence review (misoprostol, antiseptic cord care, antiseptic newborn skin care, newborn hats, safe childbirth checklist). The quality of evidence for the inclusion of a newborn hat and a checklist was poor. There are several studies in progress as well as a Cochrane Collaborative review underway that should provide high quality evidence regarding the effectiveness of chlorhexidine. Substantial, high-quality evidence is currently available for the inclusion of misoprostol in situations where oxytocin is not available or administration not feasible.

3. Results from field testing of the CBK Implementation Decision Guide

A draft CBK Implementation Decision Guide was developed to provide a practical tool, based on the available data, for use by policy makers and program managers who are considering the potential role of clean birth kits in their strategy for care at birth. The decision guide includes three algorithms to guide user through the specific steps required in making the country-level decision about whether to use CBKs:

The guide was field tested in Pakistan at both the Federal and Provincial levels. 10 in-depth interviews were conducted with federal policy makers who tested the decision guide. A focus-group discussion was held with mid-level managers after testing the guide and 96 Implementers (from Punjab and Sindh) were surveyed.Participants felt the guide was helpful for brainstorming and discussion:

“It made the concept much clearer. The thoughts are there, and the algorithm brought clarity and focus to go forward.”

Participants in the CBK Working Group meeting concluded that the guide should be repositioned as a Discussion guide rather than a Decision guide as the policy environment is often key to public health decision-making and is not factored into this model. Additional opportunities to field test the discussion guide will be sought.

The afternoon was spent identifying, through a modified CHNRI process, critical evidence gaps that remain and determining which policy/program products require further refinement and dissemination. It is likely that the WG will continue its efforts over the next several months.

In sum, members of the CBKWG feel that much progress has been made in shedding light on the often contentious debate surrounding the public health value of CBKs. As we all know in this line of work, conclusive answers are illusive and the world keeps turning as we deliberate, deliberate, deliberate on policy recommendations. Perhaps the current state of knowledge is best stated in the policy brief that was produced last year, Clean Birth Kits—Potential to Deliver?:

“There are still 60 million home births each year. There is evidence to support the importance of clean birth practices—such practices can and must be promoted. Clean birth kits have already been made available to mothers in over fifty less developed countries, however robust evaluations are lacking regarding the contribution of these kits. We consider that mother-held CBKs are appropriate in conflict or humanitarian emergencies, or in settings where there is currently low coverage of facility birth, as long as CBKs do not act as a disincentive for facility birth.” 

>Read Claudia's first post on CBK's: Clean Birth Kits: To use or not to use? That is the question