Addressing Critical Knowledge Gaps in Newborn Health

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

Clean birth and postnatal care practices to reduce neonatal deaths from sepsis and tetanus: a systematic review and Delphi estimation of mortality effect
By H Blencowe, S Cousens, LC Mullany, ACC Lee, K Kerber, S Wall, GL Darmstadt, JE Lawn,
BMC Public Health


This review is part of a BMC supplement series - Technical inputs, enhancements and applications of the Lives Saved Tool (LiST)

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.

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).

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.

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)).

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.

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Thank you for sharing with us this informative details about natal care. It is an infallible truth that clean birth and post natal care droop mortality rates, since infections in newborns are shunned. To add, we know that a newborn's immune system is not nearly as effective as an adult's or even an older child's, and that it takes months before a newborn can fight off infection. That is the reason why infections in newborns continue to be an important cause of mortality worldwide.

But, what if this infant deaths continue to rise? What if the death of infants are caused by hospital acquired infections? The query would be, could this be a case of negligence? or malpractice on the part of the medical staff? This reminds me of the article written by Mr. Haskell, a popular lawyer in Spokane WA that has won a bunch of million dollar legal claims. Here it is: Medical Mistakes -- A Primer on the Basics of Medical Malpractice. That will supplement everybody with information about medical issues, and will widen horizons about medical malpractice.

Now, what is the bottom-line here? Not all deaths happened in health institutions are MEDICAL MALPRACTICE. There are so called legal aspects that must be considered before concluding the case. In my opinion, maintaining aseptic technique during and after the birth process must not only be considered to avoid escalation of mortality rate. Understanding the immune mechanisms that operate in newborns are also necessary for the development of new approaches to improve the health of newborns. I believe this could shun the infant mortality rate from accruing.

Les conditions de travail dans lesquelles les accouchements se dirigent favorisent le tetanos et la septicémie néonatale. Encourager les accoucheuses à utiliser les moyens de proprété de bord qu'elles peuvent trouver localement peut contribuer à la dminution de ces maladies. Que les decideurs aussi disponibilisent le matériel et les infrastructures adéquats pour la bonne marche du travail.