The link between hand hygiene and maternal genital tract sepsis in healthcare facilities was established well over a century ago (1). More recent evidence exists on the association between hand hygiene and healthcare associated infections (HAIs) in infants (2).
Cleanliness of birth attendants’ hands is fundamental to ensure a clean delivery, especially when hands are in direct contact with entry sites for potential pathogens, but also to ensure cleanliness of other procedures. For example, a clean cord-cut requires clean blades and cord clamps, but hands also need to be clean; otherwise, they might contaminate the cord-cutting instruments. With an increasing number of women delivering in healthcare facilities in low and middle income countries (LMICs), appropriate hand hygiene compliance of healthcare workers on the labour wards is pivotal to preventing infections.
The HANDS Project, funded by the Medical Research Council, was a cross-sectional study investigating the barriers and facilitators of compliance to hand washing across 10 high-volume maternity units in Zanzibar. Local midwives were trained as investigators to collect data across the focus maternity units. 103 birth attendants were closely observed and everything they did with their hands during their eight hour shift was recorded on a tablet using time-&-motion methods. Our investigators worked incredibly hard to gather the required data, staying for 24 hour periods for at least five days at each facility.
Following detailed analysis of the data collected, results highlighted the importance of focusing not only on improving hand washing/rubbing but also that much of the failure to comply to WHO hand hygiene guidelines was driven by recontamination of hands or gloves on potentially contaminated surfaces after hand washing/rubbing (3).
A two day workshop was held in March 2017 to further interpret the findings, with participants including the Ministry of Health and Social Welfare (MoH), JHPIEGO and WaterAid Tanzania. The workshop included group discussions about how results could be used to promote good hand hygiene practices. Two focus groups were also held with orderlies where discussions were had about the maternity ward layout and how restructuring could improve workflow, making practicing good hygiene easier.
Following the workshops, the next stage of the project was to implement the changes discussed. The results were fed back directly to each participating facility. Importantly, the MoH focused the celebratory and educational activities of International Day of the Midwife to discuss hand hygiene. In addition, pilot interventions were tested to improve hand hygiene compliance. Delivery kits (including cord clamps, scissors, gauzes and cotton) were introduced in the second largest hospital, along with hand gel to improve hand hygiene at one of the main referral hospitals.
The results of HANDS study have yielded valuable insights into birth attendants’ hand hygiene, but also lessons around hand recontamination and hand hygiene monitoring using time-&-motion methods that could have implications in the wider healthcare environment. Soapbox’s Giorgia Gon also earned her PhD for her work on this project. For more information see Soapbox Publications.
References
- Gould IM. 2010. Alexander Gordon, puerperal sepsis, and modern theories of infection control–Semmelweis in perspective. The Lancet. Infectious Diseases 10: 275–8.
- Allegranzia B, Pittet D (2009) Role of hand hygiene in healthcare-associated infection prevention. Journal of Hospital Infection; 73, 305e315.
- Gon G, et al. (2019). Hands washing, glove use, and avoiding recontamination before aseptic procedures at birth: A multicenter time-and-motion study conducted in Zanzibar. American Journal of Infection Control.
The HANDS Project was funded by The Medical Research Council. Project partners in Zanzibar include the Ministry of Health and Social Welfare Zanzibar, JHPIEGO, WaterAid Tanzania and the University of Aberdeen.