Association between umbilical cord hygiene and neonatal sepsis among neonates presenting to a primary care facility in Nairobi County, Kenya: a case-control study

Abstract

Background: Three-quarters of all annual neonatal deaths in developing countries are attributable to neonatal sepsis. In primary care settings, poor cord hygiene due to improper handling of the infant’s cord is a major contributor to the occurrence of neonatal sepsis. The objective of this study was to describe the umbilical cord practices among mothers attending a primary care facility, assess the relationship between umbilical cord hygiene and neonatal sepsis, its impact on the population, as well as the influence of other neonatal and maternal factors on this relationship. Methods: A case-control study was conducted to assess the umbilical cord hygiene-neonatal sepsis relationship among neonates attending a primary care facility between August and October 2018. All cases were selected, while controls were systematically random sampled, as per study eligibility criteria. Exposure variables were summarized using descriptive statistics. A multivariable logistic regression model was fitted to evaluate the association between umbilical cord hygiene and neonatal sepsis adjusting for the effect of potential confounders. Subsequently, a population attributable fraction (PAF) was estimated. Results: The proportion of mothers with improper hygiene was 35.3%: 72.1% among the cases and 16.3% among the controls’ caregivers. The odds of neonatal sepsis were 13 times higher (OR=13.24; 95% CI: [7.5; 23.4]) among infants whose caregivers had improper hygiene compared to those who had proper hygiene. None of the neonatal and maternal covariates confounded the umbilical cord hygiene-neonatal sepsis association. This odds ratio gave a PAF of 66.7% (95% CI: 62.5; 69.0). Conclusions: Improper cord hygiene is prevalent in this low resource setting. Improper cord hygiene has a strong positive association with neonatal sepsis. Observing good cord care practices could avert up to 67% of newborn infections. This calls for inclusion of comprehensive cord care practices in the antenatal care educational package.

Cost and consequences of using 7.1% chlorhexidine gel for newborn umbilical cord care in Kenya

“…The analysis compared two treatment approaches: DCC (assumed to be standard of care) and CHX application (Figure 1). Patients were assumed to receive either CHX or DCC; however, in many low-and middle-income countries, mothers often choose to apply other remedies; such as methylated spirits and ash on the cord [3,4]. As this analysis used data that re ects the WHO guidelines on recommended cord care [29] and the available clinical trial data [16, 17,24], it does not include the use of other substances; therefore, it represents a conservative analysis.…”

“…Medication costs: These model inputs were based on WHO guidelines, Kenya Paediatric guidelines and expert clinical opinion and assume the medication used and duration of treatment for omphalitis is in uenced by sector and setting of care [4,27] (Supplementary Tables 2 and 3). Costs were calculated using the cost of the medication by pack/vial, dosage prescribed and treatment length (in days).…”

“…Umbilical-cord infections (omphalitis) are a major cause of neonatal mortality in low-and middle-income countries [1], where the newly cut umbilical cord can be an entry point for bacteria, causing newborn sepsis and death [2]. The causes of neonatal infection may be related to cord-care choices postpartum, including cultural practices of applying traditional substances, such as cow dung or ash, that may be harmful to the umbilical cord as part of postnatal care [3,4]. Cord care also includes the use of gentian violet, silver sulphadiazine, topical antibiotics, and methylated and surgical spirits [3][4][5].…”

“…CHX is associated with reduced infection and omphalitis rates compared with DCC in studies conducted in low-resource settings [15][16][17]; therefore, the use of CHX could lead to reductions in subsequent healthcare costs. However, DCC is not necessarily the standard of care in low-and middleincome countries, where mothers may frequently use a potentially harmful product on the cord [3][4][5].…”

“…Given the WHO recommendations and national clinical guidelines supporting the use of CHX in home-birth settings with high neonatal mortality rates, understanding the economic consequences of upscaling the use of CHX may be helpful in supporting investment decisions. These analyses are viewed as relevant for Kenya because there is variation in neonatal mortality rates between counties [22], and despite the move towards scale-up of CHX as part of routine postnatal care, a prominent proportion of neonates still receive improper cord-care hygiene [4]. Evidence suggests that supply of locally manufactured CHX is still fragmented and barriers to widespread use of CHX persist [13].…”