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HighlightsTo our knowledge, this is the first study to systematically examine recontamination after hand hygiene in a low- and middle-income country.Hand hygiene compliance before aseptic procedures was low (9.6%) among birth attendants in Zanzibar.Birth attendants did not avoid recontamination half of the time after hand rubbing/washing or glove donning.Recontamination should be investigated further to inform better behavior-change strategies.

Cultural, ecological, familial and physiological factors consistently influence fertility behaviours, however, the proximate psychological mechanisms underlying fertility decisions in humans are poorly understood. Understanding the psychological mechanisms underlying human fertility may illuminate the final processes by which some of these known predictors have their influence. To date, research into the psychological mechanisms underlying fertility has been fragmented. Aspects of reproductive psychology have been examined by researchers in a range of fields, but the findings have not been systematically integrated in one review. We provide such a review, examining current theories and research on psychological mechanisms of fertility. We examine the methods and populations used in the research, as well as the disciplines and theoretical perspectives from which the work has come. Much of the work that has been done to date is methodologically limited to examining correlations between ecological, social and economic factors and fertility. We propose, and support with examples, the use of experimental methods to differentiate causal factors from correlates. We also discuss weaknesses in the experimental research, including limited work with non-WEIRD (western, educated, industrialized, rich and democratic) populations.

Background Healthcare associated infections (HAI) are estimated to affect up to 15% of hospital inpatients in low-income countries (LICs). A critical but often neglected aspect of HAI prevention is basic environmental hygiene, particularly surface cleaning and linen management. TEACH CLEAN is an educational intervention aimed at improving environmental hygiene. We evaluated the effectiveness of this intervention in a pilot study in three high-volume maternity and newborn units in Dar es Salaam, Tanzania. Methods This study design prospectively evaluated the intervention as a whole, and offered a before-and-after comparison of the impact of the main training. We measured changes in microbiological cleanliness [Aerobic Colony Counts (ACC) and presence of Staphylococcus aureus] using dipslides, and physical cleaning action using gel dots. These were analysed with descriptive statistics and logistic regression models. We used qualitative (focus group discussions, in-depth interviews, and semi-structured observation) and quantitative (observation checklist) tools to measure why and how the intervention worked. We describe these findings across the themes of adaptation, fidelity, dose, reach and context. Results Microbiological cleanliness improved during the study period (ACC pre-training: 19%; post-training: 41%). The odds of cleanliness increased on average by 1.33 weekly during the pre-training period (CI = 1.11–1.60), and by 1.08 (CI = 1.03–1.13) during the post-training period. Cleaning action improved only in the pre-training period. Detection of S. aureus on hospital surfaces did not change substantially. The intervention was well received and considered feasible in this context. The major pitfalls in the implementation were the limited number of training sessions at the hospital level and the lack of supportive supervision. A systems barrier to implementation was lack of regular cleaning supplies. Conclusions The evaluation suggests that improvements in microbiological cleanliness are possible using this intervention and can be sustained. Improved microbiological cleanliness is a key step on the pathway to infection prevention in hospitals. Future research should assess whether this bundle is cost-effective in reducing bacterial and viral transmission and infection using a rigorous study design.

Abstractobjectives Skilled attendance at birth is key for the survival of pregnant women. This study investigates whether women at increased risk of maternal and newborn complications in four East African countries are more likely to deliver in a health facility than those at lower risk.methods Demographic and Health Survey data for Kenya 2014, Rwanda 2014-15, Tanzania 2015 and Uganda 2011 were used to study women with a live birth in the three years preceding the survey. A three-level obstetric risk index was created using known risk factors. Generalised linear Poisson regression was used to investigate the association between obstetric risk and facility delivery.results We analysed data from 13 119 women across the four countries of whom 42-45% were considered at medium risk and 12-17% at high risk, and the remainder were at low risk. In Rwanda, 93% of all women delivered in facilities but this was lower (59-66%) in the other three countries.There was no association between a woman's obstetric risk level and her place of delivery in any country; greater wealth and more education were, however, independently strongly associated with facility delivery.conclusions In four East African countries, women at higher obstetric risk were not more likely to deliver in a facility than those with lower risk. This calls for a renewed focus on antenatal risk screening and improved communication on birth planning to ensure women with an increased chance of maternal and newborn complications are supported to deliver in facilities with skilled care.