May 3, 2018
By Pavani K. Ram, MD, Associate Professor of Epidemiology and Environmental Health and Co-Director, Community for Global Health Equity, University at Buffalo; and Senior Medical Advisor for Newborn Health, Office of Maternal Child Health and Nutrition, USAID
Newborn babies the world over are cherished and welcomed into the world with loving hands. Traditions to celebrate and protect newborns are deeply culturally rooted. In parts of South Asia, for example, many mothers apply kohl to the cheek, forehead, or umbilical cord stump of their babies, warding off “evil eyes”. And in many countries, mothers are often cocooned with their babies for the first 40 to 45 days of life, with the intent of protecting both of them from the potential harms of contact with outsiders.(1)
Despite all the sociocultural efforts to protect newborns, about 2.7 million babies die annually in the newborn period, the first 28 days of life. The greatest risk of newborn mortality is during the first day of life. Whereas preterm birth and intrapartum complications account for the majority of early newborn deaths, the majority of deaths during the late newborn period between 8 and 28 days are attributed to infections. Possible serious bacterial infection, pneumonia, and omphalitis (infection of the umbilical cord stump), among other infectious processes, account for approximately 390,000 newborn deaths annually. Activities to prevent newborn infections span the continuum from the antenatal period, through to labor and delivery, and the postnatal period. Perhaps, the most crucial opportunity for preventing transmission of pathogens to the newborn is during and after labor and delivery, and in the early postnatal period.
Extensive efforts have been made in the past decade to reduce newborn mortality, through increased coverage of essential newborn care services, including health facility delivery. Rates of facility delivery have increased to greater than 80% in 11 countries in sub-Saharan Africa and South Asia. Despite these improvements, in the Democratic Republic of Congo, 80% of women report delivering at health facility but the neonatal mortality rate is still high at 28 deaths per 1000 live births. As we succeed in dramatically increasing rates of facility delivery, we may be exposing mothers and babies to the potential risks of healthcare-associated infections and exposure to pathogens circulating in the healthcare environment.(2) The prevalence of healthcare-associated infections in low- and middle-income countries is many times that observed in high-income countries.(3)
In low-resourced environments, numerous factors contribute to the risk of healthcare-associated infections during the vulnerable newborn period. A global analysis by the World Health Organization identified important gaps in availability of water, sanitation and hygiene in health facilities, with approximately 35% of facilities globally lacking handwashing stations, the most basic of infection prevention tools. Among public facilities providing labor and delivery services in one survey, fewer than 30% in Tanzania and fewer than 40% in Kenya were noted to have improved water and sanitation conditions.(4) Even when materials for infection prevention are available, there can be important gaps in hygiene behavior. Between 2009 and 2012, important lapses in infection prevention were observed in health facilities already receiving assistance to strengthen maternal and newborn care services in six sub-Saharan African countries.(5) Health workers washed their hands during only 37% of occasions of assisting pregnant women in delivery, although 89% of facilities had soap and water and 73% had clean or sterile gloves available.
In a recent study funded by USAID and conducted in 6 health facilities in Nigeria, a multitude of risks were posed by inadequate hand hygiene practices among health workers providing labor and delivery, and postnatal care services. Women in labor underwent numerous vaginal examinations by health workers but proper hygiene protocol, including handwashing with soap followed by glove use, preceded only a few of those procedures, despite availability of soap and water for handwashing in all labour and delivery areas. Similarly, the complete hygiene protocol was practiced in a vast minority of aseptic procedures during labor and delivery, such as artificial rupture of membranes and manual removal of the placenta. Whereas important gaps in hand hygiene were observed during labor and delivery, there was a near absence of hand hygiene facilities in post-natal care areas and handwashing with soap among health workers, mothers, and visitors was exceedingly rare. Nearly all newborns had physical contact by numerous visitors, without anyone washing hands before holding the baby.
Hand hygiene is a linchpin of infection prevention and control efforts in healthcare facilities. On this Global Hand Hygiene Day, May 5th, we must recommit to understanding and responding to the key structural, organizational, and psychosocial barriers to hand hygiene among health workers caring for mothers and newborns. The absence of guidelines for infection prevention and control tailored to neonatal and pediatric populations hampers development of strong national and facility level IPC plans.(6) However, the World Health Organization’s Guidelines on Core Components of Infection Prevention and Control offer a robust basis for tailoring strategies to strengthen hand hygiene and other IPC practices among health workers caring for mothers and newborns.
Newborns deserve to be brought into the world, and cared for, by hands that are not only caring but also clean.
Photos: DFID, WASHPlus
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