Hand washing glove use, and avoiding recontamination before aseptic procedures at birth: A multicenter time-and-motion study conducted in Zanzibar

Giorgia Gon (Corresponding Author), Marijn de Bruin, Micheal de Barra, Said M. Ali, Oona M. Campbell, Wendy J. Graham, Mohammed Juma, Stephen Nash, Claire Kilpatrick, Loveday Penn-Kekana, Sandra Virgo, Susannah Woodd

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Objectives To assess the hand hygiene (HH) compliance before aseptic procedures among birth attendants in the10 highest-volume facilities in Zanzibar. We also examined the extent to which recontamination contributes to poor HH; recording exact recontamination occurrences is not possible using the existing World Health Organisation HH audit tool. Methods In this time-&-motion study, three trained coders used the WOMBATv2 software to record the hand actions of all birth attendants present in the study sites. The percentage compliance and 95% confidence intervals for individual HH behaviours and for behavioural sequences during labour and delivery were calculated. Results We observed 104 birth attendants and 781 HH opportunities before aseptic procedures. Compliance to hand rubbing/washing was 24.6% (CI:21.6-27.8). Only 9.6% (CI:7.6-11.9) also donned gloves and avoided glove recontamination. Half of the time when rubbing/washing or glove donning was performed, hands were recontaminated prior to the aseptic procedure. Conclusions In this study, HH compliance by birth attendants was poor before aseptic procedures. To our knowledge this is the first study in a LMIC to show the large contribution to poor HH compliance from hand and glove recontamination before the procedure. Recontamination is an important driver of infection risk from poor HH and should be understood for the purposes of improvement and therefore included in HH monitoring and interventions.
Original languageEnglish
Pages (from-to)149-156
Number of pages8
JournalAmerican Journal of Infection Control
Issue number2
Early online date4 Oct 2018
Publication statusPublished - Feb 2019

Bibliographical note

The project was funded by the Medical Research Council – PHIND scheme. Award number MR/N015975/1. The Soapbox Collaborative also contributed by funding staff involved in this project. The writing up of this paper provided part of the background needed for the CLEAN Study funded by the UK Joint Global Health Trials (Wellcome, MRC, DFID and DOH) Award number: MR/R019274/1.

We thank the Ministry of Health of Zanzibar for their participation and engagement in the study. A special thanks to Rukaiya M Said, Mwanafatima Ali Mohammed, Bijuma Mkubwa Abdallah, and Asya Hati Vuai who collected all the data. We also thank Marina Daniele for participating in the consultation exercise aimed at refining the definition of opportunity. Finally, we thank Daniel Powell and David Macleod for the support in data management.

Data sharing
Anonymized data at the opportunity level are available in Appendix F, from https://doi.org/10.17037/DATA.00000778.


  • maternal health
  • newborn health
  • hand hygiene
  • behavioural medicine
  • labour ward
  • Tanzania
  • Hand hygiene
  • Behavioral medicine
  • Newborn health
  • Labor ward
  • Maternal health


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