Supply kits for antenatal and childbirth care: a systematic review

Supply kits are considered a potential strategy to improve maternal and child health, as they provide medication or diagnostic tests at the same time. This review searched for all published studies that tested the use of supply kits and assessed their effectiveness and safety. The studies found were of moderate to low quality. Most of them suggested benefits for mothers and babies, namely, reduced mortality and morbidity, with the use of supply kits. We concluded that although more research is needed to more comprehensively evaluate this strategy, it seems potentially useful for maternal and child health.

Improving maternal health and reducing child mortality were two of the eight Millennium Development Goals (MDGs) adopted by the international community in 2000. Between 1990 and 2015, the number of global maternal deaths dropped by 43% (from 532,000 to 303,000) [1]. To accelerate this decline, countries have established the Sustainable Development Goals (SDGs) as a follow-up initiative. Two targets are included under SDG 3: to reduce the global maternal mortality ratio to less than 70 per 100,000 births, with no country having a maternal mortality rate more than twice the global average, and to end preventable deaths of newborns, with all countries aiming to reduce neonatal mortality to 12 per 1000 live births [2].

Most maternal deaths are preventable, as the healthcare solutions to prevent or manage potential maternal complications are well known [1]. However, several factors can prevent the uptake of interventions that have been proven to be efficient and beneficial, specifically during pregnancy and delivery [3]. Supply chain deficiencies and stock-outs are among the most limiting barriers that hinder the delivery of effective practices in poor-resource settings [4‐9]. Supply kits (packaged supplies targeting women, healthcare providers or health facilities) have been proposed to be a simple and low-cost intervention that can address various challenges routinely encountered in low-income countries. In the area of maternal and newborn health, supply kits have been designed to focus on issues ranging from timely availability of effective treatment in emergency situations and avoidance of stock-outs for routine care to achieving clean childbirth and reducing the incidence of infections and the associated complications, particularly in areas where women give birth at home [10‐13]. Different types of supply kits have been implemented and tested as single or multicomponent interventions, and reviews assessing their effectiveness have been conducted, the latest of which was published in 2012 [14]. The timely update of the evidence is important for policy makers and implementers planning to use supply kits to improve care in areas where supply change deficiencies and stock-outs are a major bottleneck to reaching women with effective screening and treatment interventions. Even if the proportion of women delivering in health facilities is increasing, births often occur in a place with sub-standard hygienic conditions within the facility, without appropriately trained staff or without the appropriate medicines and conditions [15, 16].

The objective of this systematic review was to update and summarise the evidence with focus on the uptake, effectiveness and safety of supply kits for maternal care, particularly for antenatal and childbirth care at both institutional and community level.

The methodology and reporting of results in this systematic review followed all steps proposed in the PRISMA statement [17]. This review was registered in the Prospero Centre for Reviews and Dissemination, University of York, with the number CRD42016043145 [18].

This systematic review identified 24 manuscripts, of which four were systematic reviews and 20 primary studies (primary data collection or secondary data analyses) presenting information on the uptake and impact of supply kits during pregnancy, childbirth or immediate postpartum period. The majority involved single-use kits for clean childbirth and infection prevention. Most studies were published in peer-reviewed journals, had a sample size of less than 1000 women and were observational studies. Only one study was a randomized controlled trial.

In most of the studies, the kits were used by more than half of the participants, with higher use shown at home than at the facility. In general, the group using the supply kits showed better measured outcomes. However, most of the included studies assessed the use of kits in the context of a complex intervention, and thus it was impossible to conclude that the kits were responsible for the observed differences. The groups using supply kits showed a statistically significant positive effect on neonatal outcomes; including reduced cord infection [13, 40, 42], sepsis [35, 43], neonatal mortality [10, 30, 43] and perinatal mortality [30]. Several studies showed a statistically significant decrease in maternal adverse outcomes in the group using supply kits (see Table 6) including reduction in puerperal infection [13, 30, 40] and postpartum haemorrhage [11, 30, 39] and a non-significant reduction in maternal mortality [11, 30, 46].Meta-analysis was deemed inappropriate due to the heterogeneity in the study designs, in the content of the supply kits, in the definition of compliance in use of supply kits and in the outcomes measured.

One study depicted potential adverse effects related to supply kits: a decrease in institutional childbirth in HIV-positive women who received the kit containing antiretroviral medication. Nonetheless, HIV-positive women compose a very specific group of women and might have different behaviours related to seeking antenatal and delivery care compared to the others [12].

This review showed that the most tested type of supply kit was the CDK. Eighteen studies evaluated kits with all or some of the components of the CDK (Table 2) and showed positive results in increasing clean delivery practices (Table 4). It has been estimated that clean childbirth practices could avert 6–9% of the 1.16 million newborn deaths in sub-Saharan African countries [31]. However, controversy remains regarding the independent effect of each component or clean practice. Seward et al. [38] conducted the only study that separately examined the effect of kit use and hand washing. They found that while hand washing with soap before delivery was independently associated to a reduction in maternal mortality, kit use had no significant effect on the prevention of maternal deaths. Similarly, Tsu et al. [42] reported that hand washing with soap before cutting the cord vs. not washing hands reduced cord infection even more than using a complete CDK. Balsara et al. [32] found no difference between kits’ users and non-users with regard to whether the birth occurred on a clean or unclean surface. These findings suggest that not all CDK components are used or have the same value in improving outcomes. Cultural beliefs may play a role in the understanding of the benefits of using certain components. For example, it could be difficult to understand the usefulness of laying down a plastic sheet during childbirth for women accustomed to delivering in a vertical position [41]. In addition, in our review, only five studies evaluated the effect of supply kits alone, and these studies were all heterogeneous (See Table 1).

Compliance with the “use of CDK” is not defined in the same way across studies, and this adds uncertainty to the conclusions. For example, Winani et al. [40] considered three different scenarios to define when a woman had “used a kit”: 1) if she used the full CDK or at least the plastic sheet and either the razor blade or cord tie (or both); 2) if she used the razor blade and cord tie only; or 3) if she used the razor blade alone. This resulted in heterogeneity and weakened the conclusions. In addition, the content of supply kits somewhat varied (see Table 3). However, considering the objective and concept of the kits, the components most frequently included were the sterile razor (n = 15 kits), cord tie (n = 14 kits) and soap (n = 11 kits).

In this review, all studies except one were conducted in developing countries, mainly in Africa and Asia. In low-resource settings, the use of supply kits is intended to facilitate the provision of interventions by providing all the resources needed for a given situation at one time. In addition, it optimizes the scarce contact between women and the healthcare system in areas where barriers related to accessibility, knowledge and lack of satisfaction prevent women from engaging with the system. In countries with a high prevalence of home births, CDK may be an effective option for reducing newborn infections as well as puerperal sepsis or other genital tract infections following childbirth. The successful implementation of supply kits minimizes the burden of having to separately acquire its contents, which would require knowledge of what is needed and how to use it. This is likely an unrealistic expectation in these settings. The challenges mentioned above justified the implementation of these studies in settings where maternal and neonatal mortality remains high.

We found only one study that described the use of a kit designed to address stock-outs and deficiencies in procurement at the facility level [11]. This kit aimed to address the delay in accessing treatment for obstetric emergencies at the health facility level once women were in the facility by considering the context of a dysfunctional supply chain and busy maternity units. In countries with weak and overstretched health systems, stock-outs in medicines and equipment occur routinely and hinder the delivery of effective practices even when women reach the health facility. These kits, which are not intended for individual use, may contain all the supplies required to attend 100 births or to conduct 100 ANC visits, for example. This type of kit has been tested recently in Mozambique in a WHO cluster randomized controlled trial [47]. Further research on the effectiveness and feasibility of this type of kit is warranted because procurement inefficiencies are a chronic and contemporary challenge in many low-resource settings and remote areas.

Even when the acceptability is high and when kits include instructions, the distribution of kits do not guarantee its use. Different studies have employed several approaches to provide access to supply kits including distribution through health facilities, community health workers, TBAs and private providers, such as pharmacists. However, the provider-specific impact on the uptake of supply kits has not been studied. Seward et al. [38] discussed the effect of a complex intervention using a participatory learning and action cycle with women’s groups in India and Nepal [38, 48, 49]. The discussions of clean delivery and care-seeking behaviours in women’s groups showed an increased uptake in reporting the use of kits in the intervention arm, compared to the control arm.

Available qualitative data is aligned with our results [50]. The main barriers to the implementation of supply kits are those related to socio-cultural and popular beliefs that birth preparation could bring bad luck. Financial constraints and a limited understanding of the instructions on how to use the supply kits have been also identified as accessibility barriers. On the other hand, convenience, the perception of the components as hygienic, and avoidance of delays in receiving care were viewed as satisfactory features that would incentivize the use of the supply kits.

Although four reviews have been previously published on this topic, this systematic review includes an additional four years of evidence, which combined with the current available qualitative evidence [50], it adds a more comprehensive approach to pre-existing knowledge. When the evidence on effectiveness is substandard and based on observational studies, the use of other types and sources of information can be critical to gain a better understanding of the intervention and the pathways of action. This is even more important for complex interventions. In addition, previous reviews have focused on the use of supply kits to reduce neonatal mortality and morbidity [28, 29], kits to conduct family and community interventions [27] and kits designed exclusively for birth [14]. Our review included supply kits for pregnancy and a larger range of maternal and neonatal outcomes.

Studies found in this review reported a reduction in maternal and neonatal morbidity (particularly infection-related morbidity) and neonatal mortality in the groups using supply kits. However, these findings should be interpreted with caution because virtually all the evidence was derived from observational studies and was thus prone to bias and because the effects observed cannot be ascribed to the supply kits alone, given their inclusion in multi-component interventions. The potential bias of the studies analysed and the heterogeneity hinder the reliability of identifying an overall effect of the kits. It would appear appropriate to continue its use and to expand to other preventive or therapeutic interventions with the inclusion of strong monitoring and evaluation strategies that include comparisons to control groups, as these methods could provide more evidence regarding the real effect of the kits.