Safe and respectful? Birth attendants’ hand hygiene compliance and its determinants using nationally representative data from Kenya, Malawi and Nepal

Background: In low and middle-income countries (LMICs), infections acquired during childbirth contribute significantly to maternal and neonatal mortality. Hand hygiene (HH) is critical in preventing the spread of infections, yet compliance remains inadequate. This study investigates birth attendants’ HH compliance during labour, delivery, and postpartum in LMICs, using nationally representative data from Service Provision Assessments (SPAs) in Kenya, Malawi, and Nepal. Methods: We analysed 1565 observed deliveries across 517 health facilities, resulting in 3919 HH opportunities. The outcomes were hand washing or hand disinfectant use: (1) before any initial examination, (2) before aseptic procedures during labour, (3) after birth. We used descriptive statistics to assess HH compliance and multivariate multilevel mixed-effect logistic regressions to investigate determinants, accounting for facility and individual clustering. Findings: Hand hygiene compliance varied significantly across countries, with Kenya showing the lowest rates, while Malawi and Nepal had higher compliance levels. Supportive and effective communication towards pregnant women was significantly associated with an increase in HH compliance before the vaginal examination (Kenya - OR: 5.94, 95% CI 1.68-21.0; Malawi - OR: 2.19, 95% CI 1.04–4.65) and before aseptic procedures (Kenya - OR: 4.03, 95% CI 1.81–8.96; Malawi - OR: 4.01, 95% CI 1.69–9.50; Nepal - OR: 2.66, 95% CI 1.30–5.44). HH compliance during aseptic procedures during labour was also associated with recent IPC training in Malawi (OR: 3.48,95%CI 1.44–8.41) and facility infrastructure (OR: 6.14,95%CI 1.07–35.3). Conclusion: Low hand hygiene compliance during birth, especially before aseptic procedures, can lead to healthcare-associated infections with serious consequences for mothers and newborns. Future research should investigate further the association between effective communication and hand hygiene.