BackgroundNeonatal infections caused by unsafe umbilical cord practices account for the majority of neonatal deaths in Nigeria. We examined the trends in umbilical cord care practices between 2012 and 2015 that coincided with the introduction of chlorhexidine digluconate 7.1% gel in Bauchi and Sokoto States.MethodsWe obtained data from three rounds of lot quality assurance samples (LQAS) surveys conducted in 2012, 2013 and 2015. Households were randomly sampled in each round that totaled 1140 and 1311 households in Bauchi and Sokoto States respectively. Mothers responded to questions on cord care practices in the last delivery. Coverage estimates of practice indicators were obtained for each survey period. Local Government Area (LGA) estimates for each indicator were obtained with α ≤ 5%, and β ≤20% statistical errors and aggregated to State-level estimates with finite sample correction relative to the LGA population.ResultsOver 75 and 80% of deliveries in Bauchi and Sokoto States respectively took place at home. The proportion of deliveries in public facilities reported by mothers ranged from 19% in 2012 to 22.4% in 2015 in Bauchi State and from 12.9 to 13.2% in 2015 in Sokoto State. Approximately 50% of deliveries in Bauchi and more than 80% in Sokoto States were assisted by traditional birth attendants (TBAs) or relatives and friends, with little change in the survey periods. In Bauchi and in Sokoto States, over 75% and over 80% of newborn cords were cut with razor blades underscoring the pervasive role of the TBAs in the immediate postpartum period. Use of chlorhexidine digluconate 7.1% gel for cord dressing significantly increased to the highest level in 2015 in both States. Health workers who attended deliveries in health facilities switched from methylated spirit to chlorhexidine. There were no observable changes in cord care practices among the TBAs.ConclusionUnsafe umbilical cord care practices remained prevalent in Bauchi and Sokoto States of Nigeria, although a recent introduction of chlorhexidine digluconate 7.1% gel positively changed the cord care practices toward safer practices among public health providers. TBAs, friends and relatives played the strongest immediate postpartum roles and mostly retained the unsafe cord care practices such as use of ash, cow dung and hot compress. We recommend that existing TBAs are retrained and refocused to forge stronger links between communities and the primary health centers to increase mothers’ access to skilled birth attendants.

BackgroundPostpartum haemorrhage (PPH) is a leading cause of maternal death in Sokoto State, Nigeria, where 95% of women give birth outside of a health facility. Although pilot schemes have demonstrated the value of community-based distribution of misoprostol for the prevention of PPH, none have provided practical insight on taking such programs to scale.MethodsA community-based system for the distribution of misoprostol tablets (in 600ug) and chlorhexidine digluconate gel 7.1% to mother-newborn dyads was introduced by state government officials and community leaders throughout Sokoto State in April 2013, with the potential to reach an estimated 190,467 annual births. A simple outcome form that collected distribution and consumption data was used to assess the percentage of mothers that received misoprostol at labor through December 2014. Mothers’ conditions were tracked through 6 weeks postpartum. Verbal autopsies were conducted on associated maternal deaths.ResultsMisoprostol distribution was successfully introduced and reached mothers in labor in all 244 wards in Sokoto State. Community data collection systems were successfully operational in all 244 wards with reliable capacity to record maternal deaths. 70,982 women or 22% of expected births received misoprostol from April 2013 to December 2014. Between April and December 2013, 33 women (< 1%) reported that heavy bleeding persisted after misoprostol use and were promptly referred. There were a total of 11 deaths in the 2013 cohort which were confirmed as maternal deaths by verbal autopsies. Between January and December of 2014, a total 434 women (1.25%) that ingested misoprostol reported associated side effects.ConclusionIt is feasible and safe to utilize government guidelines on results-based primary health care to successfully introduce community distribution of life saving misoprostol at scale to reduce PPH and improve maternal outcomes. Lessons from Sokoto State’s at-scale program implementation, to assure every mother’s right to uterotonics, can inform scale-up elsewhere in Nigeria.

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