Every year 57 million women worldwide give birth without the assistance of a skilled healthcare provider, many in unhygienic settings, representing a major risk for maternal and neonatal mortality (Lawn et al., 2009; Morrison, Jacoby, Ghimire, & Oyloe, 2015). The story of Tewabech, an Ethiopian woman is a compelling example. She unexpectedly gave birth unattended on a dirt path while filling water containers two miles from her home in the small village of Lahyte. After giving birth, she carried her newborn daughter and the heavy water cans all the way back to her home alone (White, 2013).

A small and simple way to address this issue is distribution of clean birth kits (CBKs) to women in low-resource countries. It is hoped that providing childbearing women with a few basic hygiene items in a small kit can make a difference in maternal and neonatal mortality. The "six cleans" are the focus on items provided in CBKs: clean hands, clean perineum, clean birth surface, clean cord cutting implement, clean cord tying, and clean cord care. The CBK includes: a small bar of soap, a pair of plastic gloves (for the birth attendant), five 3 x 3 in. squares of gauze, a small blade (to cut the umbilical cord), three pieces of string (10 in. long each), and a small plastic sheet 1 yard by 1 yard, with a pictorial birth and hygiene instruction sheet. The CBK is packed in a sandwich-size zip lock bag.

The kits are distributed by United Nations Population Fund (http://www.globalgiving.org/projects/unfpa-clean-birthing-kits/); Worldwide Healing Hands (http://www.worldwidehealinghands.org/how-you-can-help.html); and Ayzh that focuses on the local assembly of kits (http://www.azh.com/). Birthing Kit Foundation Australia donates CBKs to Medical Ship who dispenses them in Papua New Guinea (http://themommyhoodmemos.com/2012/08/bloggers-for-birth-kits-faq) where maternal mortality rates are high and access to care is limited.

If they are produced and distributed locally (through local shops directly to expectant mothers or from healthcare providers and through clinics), costs for the kits are lower than those obtained from international organizations. The CBKs from Worldwide Healing Hands or those produced locally may be culturally sensitive: for example, cutting the umbilical cord with a coin that may be very dirty is a common practice in Nepal. Out of respect for this practice, the CBKs include plastic rupees instead of a blade for cutting the cord.

Evidence for CBKs in the promotion of clean birth practices is of limited quality and often it has been studied in conjunction with multiple interventions. Systematic reviews conclude there is strong probability that CBKs should be part of community-based interventions (Lassi & Bhutta, 2015). The CBKs are cost effective. An important consideration is whether the kits act as a disincentive for women to give birth in healthcare facilities. More data are needed to assess whether or not this should be a concern.

In war-torn countries, in the face of natural disasters, humanitarian emergencies, or obstetric emergencies, CBKs are appropriate. The moment of birth in the continuum of care across the childbearing year is when mothers and newborns are at the greatest risk (Blencowe, Lawn, & Graham, 2010). The ideal goal is for every birth in every country to be attended by a skilled provider in clean conditions with quick access to emergency obstetric and neonatal care; however, too often this is not reality. In the meantime, CBKs are a viable option to save maternal/newborn lives and reduce morbidity rates of infection.

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