The Sakinah method-targeted education of traditional midwives supplemented with clean birth kits

Pakistan continues to experience high maternal and neonatal mortality. Mortality is concentrated in rural, underserved populations where home birth is common and access to skilled care is limited.

We set out to evaluate the impact of a community-delivered intervention combining clean birth kits (CBKs) with structured midwifery training on maternal and neonatal outcomes in rural Pakistan.

This was conducted as a pragmatic, community-based study in rural Punjab, beginning in September 2022 in Sillanwali and expanding to eight additional deprived sites. The intervention combined competency-based midwifery training with CBKs containing infection and hemorrhage prevention components, including misoprostol. Maternal and neonatal outcomes were prospectively recorded via a bespoke digital platform; paper forms were used in low-connectivity areas and later digitized. Implementation was monitored through supervision and record verification. The data was verified independently through structured postpartum follow-up.

In 5327 births, there were no maternal deaths. Postpartum hemorrhage (PPH) of 500 to 1000 mL was seen in 8.2%, and >1000 mL in 0.51% of pregnancies. Gestation at birth was at >37 weeks in 83.4%, with late preterm (35-36 weeks) accounting for 14.9%. There were 5245 (98.5%) live births, with 82 stillbirths (15.4/1000) and 113 neonatal deaths (21.2/1000), with a perinatal mortality rate of 36.6 per 1000. Perinatal loss was largely associated with prematurity. Compared with national outcomes (maternal mortality ratio [MMR] 155-160/100,000; stillbirth 27-28/1000; neonatal mortality 38-39/1000), the intervention cohort demonstrated lower maternal and perinatal mortality (P<.05 for MMR, P<.001 for neonatal mortality rate). PPH incidence (8.8%) was comparable to national levels (∼9%-11%).

A community-embedded package combining CBKs with structured midwifery training was associated with zero maternal deaths and reduced perinatal mortality, suggesting a cost-effective scalable strategy to improve outcomes and reduce inequities in high-risk low-resource and home-birth settings. This project embedded misoprostol within CBKs and transitioned comprehensively from abandoning poly-filament threads as cord ties to sterile clamps with early adoption of chlorhexidine. An almost 50% reduction in neonatal mortality versus national estimates underscores the effectiveness of an integrated, evidence-based package adapted for home births.