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Health Policy Plan. 2017 Oct 1;32(8):1220-1228. doi: 10.1093/heapol/czx081.

Unpacking the enabling factors for hand, cord and birth-surface hygiene in Zanzibar maternity units.

Author information

Department of Infectious Disease Epidemiology, The London School of Hygiene and Tropical Medicine, Keppel Street, WC1E 7HT, London.
The Soapbox Collaborative, Keppel Street, WC1E 7HT, London.
Public Health Laboratory - Ivo de Carneri, PO Box 122 Wawi, Chake Chake, Pemba, Zanzibar, Tanzania.
Centre for Actuarial Research, University of Cape Town, Private Bag, Rondebosch 7701, South Africa.
CSK Research Solutions, Sinza B, Mori Street, Dar Es Salaam, Tanzania.
The Ministry of Health of the Revolutionary Government of Zanzibar, Maternal and Child Health Office, Ministry of Health Zanzibar, PO Box 236, Zanzibar, Tanzania.
WaterAid, 27 Cranbrook Drive, Maidenhead, Berkshire.
The University of Sheffield, 2 Sudan Avenue, Brackley, Northamptonshire NN13?6LE, UK.
WaterAid, PO Box 33579, Dar Es Salaam, Tanzania.
WaterAid, 47-49 Durham Street, London SE11?5JD, UK.


Recent national surveys in The United Republic of Tanzania have revealed poor standards of hygiene at birth in facilities. As more women opt for institutional delivery, improving basic hygiene becomes an essential part of preventative strategies for reducing puerperal and newborn sepsis. Our collaborative research in Zanzibar provides an in-depth picture of the state of hygiene on maternity wards to inform action. Hygiene was assessed in 2014 across all 37 facilities with a maternity unit in Zanzibar. We used a mixed methods approach, including structured and semi-structured interviews, and environmental microbiology. Data were analysed according to the WHO 'cleans' framework, focusing on the fundamental practices for prevention of newborn and maternal sepsis. For each 'clean' we explored the following enabling factors: knowledge, infrastructure (including equipment), staffing levels and policies. Composite indices were constructed for the enabling factors of the 'cleans' from the quantitative data: clean hands, cord cutting, and birth surface. Results from the qualitative tools were used to complement this information.Only 49% of facilities had the 'infrastructural' requirements to enable 'clean hands', with the availability of constant running water particularly lacking. Less than half (46%) of facilities met the 'knowledge' requirements for ensuring a 'clean delivery surface'; six out of seven facilities had birthing surfaces that tested positive for multiple potential pathogens. Almost two thirds of facilities met the 'infrastructure (equipment) requirement' for 'clean cord'; however, disposable cord clamps being frequently out of stock, often resulted in the use of non-sterile thread made of fabric. This mixed methods approach, and the analytical framework based on the WHO 'cleans' and the enabling factors, yielded practical information of direct relevance to action at local and ministerial levels. The same approach could be applied to collect and analyse data on infection prevention from maternity units in other contexts.


Maternal and child health; health behaviour; health care; prevention; water

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