Reducing infection risks in maternity and neonatal wards through improved environmental hygiene: an exploratory study in The Gambia.

Context of the research
Infection is a leading cause of maternal and newborn deaths, particularly in sub-Saharan Africa where there is also a high burden of hospital-acquired infections (HAIs), and where exposure to unhygienic practices and environment further poses a substantial risk to mothers and newborns. The HAIs occurring in these settings are often caused by antibiotic-resistant bacteria, whose transmission is the result of several factors including inadequate water, sanitation and hygiene (WASH), poor infection control, inadequate cleaning, and overcrowding wards.
Aims and objectives
Our research aims to explore the role of an environmental cleaning package and its effect on some of the most vulnerable patients in African hospitals - women and newborns.
The specific objectives are:
1. To establish baseline measurements of environmental contamination in the maternity and neonatal units in two hospitals in The Gambia, including two-weekly variability in such measures;
2. To develop a contextually appropriate cleaning training package specifically for newborn units in LMICs, with a focus on sub-Saharan Africa
3. To pilot this training package intervention in two large hospitals in The Gambia and measure potential impact on environmental cleanliness.
4. To establish a network of researchers and relevant WASH/IPC stakeholders, including the regional Maternal-Newborn Infection network and Infection Control Africa Network (ICAN), and build collaborations to support a future West African trial of the same cleaning intervention across multiple regional neonatal units, bringing together academic partners in West Africa and the UK.

Potential applications and benefits
Clean and hygienic health care facilities can help establish trust in health services and encourage mothers to seek prenatal care and deliver in facilities rather than at home - two important elements of the strategy to reduce maternal and newborn mortality.
The findings from our study will also contribute new evidence for the new global action plan arising from the World Health Resolution on WASH, IPC and AMR
We will use the learning derived from this preliminary work to convene a network of researchers to build the case for a future African trial of this cleaning training package intervention against an infectious outcome across multiple neonatal units.

The aim of this research is to explore the links between environmental hygiene and infection risks in maternity and neonatal units in two hospitals in the Gambia. We will use the learning derived from this preliminary work to convene a network of researchers to build the case for a future African trial of this intervention against an infectious outcome across multiple neonatal units.
The specific objectives are
1. To establish baseline measurements of environmental contamination in the maternity and neonatal units in two hospitals in The Gambia, including two-weekly variability in such measures;
2. To develop a contextually appropriate cleaning training package specifically for newborn units in LMICs, with a focus on sub-Saharan Africa
3. To pilot this training package intervention in two large hospitals in The Gambia and measure potential impact on environmental cleanliness.
4. To establish a network of researchers and relevant WASH/IPC stakeholders, including the regional Maternal-Newborn Infection network and Infection Control Africa Network (ICAN), and build collaborations to support a future West African trial of the same cleaning intervention across multiple regional neonatal units, bringing together academic partners in West Africa and the UK.

Cleaning in newborn care units including NICUs has some important technical differences to cleaning other hospital areas. Due to the intense vulnerability of patients and the delicacy of medical equipment, typically different cleaning staff, chemical agents and physical methods are typically used. We will observe use of cleaning products and techniques, and hand hygiene as well as measure environmental contamination before and after the introduction of a cleaning training package intervention.

The proposed study is expected to impact four main groups in the society:

1) Cleaners and Cleaning Champions:
They will benefit from improved knowledge and understanding of environmental hygiene and infection prevention and control. We also expect that their cleaning performance will improve.

2) Women and newborns:
Over three-quarters of women in urban Gambia deliver in a health facility. We expect that the improved environmental cleanliness will contribute to making hospitals a more desirable place to deliver.

3) Hospital and district stakeholders:
We expect that improved environmental cleanliness with lead to a reduction in hospital acquired infection. Treatment in The Gambia is given free of charge to Antibiotics represent a significant proportion of the health budget; reducing HAI will thereby impact on length of hospital stay and drugs, including prophylactic or curative antibiotics, so decreasing drug and treatment costs. A successful regional trial could benefit the international community concerned with poor IPC and Quality of Care, as well as antimicrobial resistance, and so influence policy and practice on a large-scale

4) Policymakers and policy influencers:
National, regional, and international policymakers and influencers on IPC (including NGOs, the regional Maternal-Newborn Infection network and Infection Control Africa Network, as well as the Ministry of Health) in The Gambia and other West African countries will be invited to form a network of researchers and relevant WASH/IPC stakeholders, and build collaborations to support a future West African trial of the same cleaning intervention across multiple regional neonatal units, bringing together academic partners in West Africa and the UK.