Enablers and Barriers to Chlorhexidine Use in Umbilical Cord Care: Voices of Care Givers and Healthcare Providers in Selected Counties in Kenya
Abstract
Neonatal sepsis contributes to increased rates of mortality among newborns during their first month of life. Chlorhexidine (CHX) has proven effective in the prevention of neonatal sepsis due to umbilical stump infection after birth. Despite shifting from dry cord care techniques to CHX use, there is still a high prevalence of improper cord care in low-resource settings in Kenya. This study sought to explore barriers and enablers to CHX use in Kwale, Vihiga and Machakos counties in Kenya. We adopted mixed methods cross-sectional survey with 582 women of reproductive age with a young child less than one year as respondents to the quantitative survey. Qualitative data entailed thirty (30) key informant interviews with healthcare workers and national policymakers. Six (6) focus group discussions with mothers, caregivers, community health volunteers (CHVs) and traditional birth attendants were conducted. An observation checklist was used to assess the availability of CHX services and supplies in fourteen (14) health facilities was conducted. Results indicated variation in umbilical cord care practices for newborns across counties. Of 582 caregivers, only 1.3% reported having ever used CHX. Majority mentioned using methylated spirits (41.6%), other antiseptics (23.3%) and salty water (11.3%). Other substances used for cord care included plain water, herbal extracts, cow dung, soil, and breast milk. Despite 100% awareness of CHX among health workers, only a third of caregivers (38.7%) had heard of CHX. About 76.9% of participants preferred the gel formulation and 8.9% did not know where to get the product. Drivers of CHX use included faster cord healing, infection control in hospitals, ease of use, cost implications, ease of access, influence from key decision makers and preferred CHX formulation. Barriers included minimal awareness among caregivers, cultural practices and taboos on cord care, inadequate capacity building of CHVs on CHX, unclear CHX user guidelines for caregivers, prolonged stockouts and inadequate knowledge of CHX in communities. Healthcare workers highlighted poor dissemination of CHX guidelines by the Ministry of Health, unavailability in the Kenya Medical Supplies Authority (KEMSA) and Mission for Essential Drugs and Supplies logistic management information system making it difficult to procure. There is a need for advocacy to promote the uptake of CHX in facilities and increase knowledge of communities on CHX as well as manage the supply chain to increase CHX availability
Downloads
References
Abegunde, D., Orobaton, N., Beal, K., Bassi, A., Bamidele, M., Akomolafe, T., Ohanyido, F., Umar-Farouk, O., & Danladi, S. (2017). Trends in newborn umbilical cord care practices in Sokoto and Bauchi States of Nigeria: The where, who, how, what and the ubiquitous role of traditional birth attendants: A lot quality assurance sampling survey. BMC Pregnancy and Childbirth, 17 (1). https://doi.org/10.1186/s12884-017-1551-x
Abhulimhen-Iyoha, B. I., & Ibadin, M. O. (2012). Determinants of cord care practices among mothers in Benin City, Edo State, Nigeria. Nigerian Journal of Clinical Practice, 15 (2), 210–213. https://doi.org/10.4103/1119-3077.97320
Abhulimhen-Iyoha, B., Ofili, A., & Ibadin, M. (2011). Cord care practices among mothers attending immunization clinic at the University of Benin Teaching Hospital, Benin City. Nigerian Journal of Paediatrics, 38 (3). https://doi.org/10.4314/njp.v38i3.72262
Agossou, J., Hounnou-d’Almeïda, M., Adédémy, J. D., Noudamadjo, A., N’gobi, D. Y. G., & Ayivi, B. (2016). Newborn Umbilical Cord Care in Parakou in 2013: Practices and Risks. Open Journal of Pediatrics, 06 (01), 124–135. https://doi.org/10.4236/ojped.2016.61019
Amare, D., Mela, M., & Dessie, G. (2019). Unfinished agenda of the neonates in developing countries: magnitude of neonatal sepsis: systematic review and meta-analysis. In Heliyon (Vol. 5, Issue 9). Elsevier Ltd. https://doi.org/10.1016/j.heliyon.2019.e02519
Ambale, C., Ngatia, B., & Nthusi, J. (2019). Assessment of Chlorhexidine use for cord care at Kangundo level 4 Hospital. 1–22. https://doi.org/10.21203/rs.2.18832/v1
Coffey, P. S., & Brown, S. C. (2017). Umbilical cord-care practices in low- and middle-income countries: a systematic review. BMC Pregnancy and Childbirth, 17 (1), 1. https://doi.org/10.1186/S12884-017-1250-7
Gebremedhin, D., Berhe, H., & Gebrekirstos, K. (2016). Risk Factors for Neonatal Sepsis in Public Hospitals of Mekelle City, North Ethiopia, 2015: Unmatched Case Control Study. PLOS ONE, 11 (5), e0154798. https://doi.org/10.1371/journal.pone.0154798
Githinji, D. (2018). Chlorhexidine (CHX) gel for cord care a game changer in newborn survival in Bungoma County, Kenya.
Health, M. of, Neonatal, Child, and A. H. U. (NCAHU), (RMHSU), R. and M. H. S. U., (CHAI), (WHO), W. H. O., (UNICEF), U. N. I. C. E. F., PATH, Nairobi, U. of, International, S. the C., (JHPIEGO), M. and C. S. P. (MCSP)/Johns H. P. for I. E. in G. and O., & Initiative, C. H. A. (2016). A guideline for the use of Chlorhexidine for newborn umbilical cord care in Kenya. April, 3.
Kinanu, L., Odhiambo, E., Mwaura, J., & Habtu, M. (2016). Cord Care Practices and Omphalitis among Neonates Aged 3 - 28 Days at Pumwani Maternity Hospital, Kenya. Journal of Biosciences and Medicines, 04 (01), 27–36. https://doi.org/10.4236/jbm.2016.41004
Mallick, L., Yourkavitch, J., & Allen, C. (2019). Trends, determinants, and newborn mortality related to thermal Care and umbilical cord care practices in South Asia. BMC Pediatrics, 19 (1), 248. https://doi.org/10.1186/s12887-019-1616-2
Masaba, B. B., & Mmusi-Phetoe, R. M. (2020). Neonatal survival in sub-sahara: A review of kenya and south africa. Journal of Multidisciplinary Healthcare. https://doi.org/10.2147/JMDH.S260058
Milton, R., Gillespie, D., Dyer, C., Taiyari, K., Carvalho, M. J., Thomson, K., Sands, K., Portal, E. A. R., Hood, K., Ferreira, A., Hender, T., Kirby, N., Mathias, J., Nieto, M., Watkins, W. J., Bekele, D., Abayneh, M., Solomon, S., Basu, S., … Chan, G. J. (2022). Neonatal sepsis and mortality in low-income and middle-income countries from a facility-based birth cohort: an international multisite prospective observational study. The Lancet. Global Health, 10 (5), e661. https://doi.org/10.1016/S2214-109X (22)00043-2
Moraa, P. K., Mweu, M. M., & Njoroge, P. K. (2019a). Association between umbilical cord hygiene and neonatal sepsis among neonates presenting to a primary care facility in Nairobi County, Kenya: A case-control study. F1000Research. https://doi.org/10.12688/f1000research.19544.2
Moraa, P. K., Mweu, M. M., & Njoroge, P. K. (2019b). Association between umbilical cord hygiene and neonatal sepsis among neonates presenting to a primary care facility in Nairobi County, Kenya: A case-control study. F1000Research, 8. https://doi.org/10.12688/f1000research.19544.2
Moraa, P. K., Mweu, M. M., & Njoroge, P. K. (2019c). Association between umbilical cord hygiene and neonatal sepsis among neonates presenting to a primary care facility in Nairobi County, Kenya: a case-control study. F1000Research, 8. https://doi.org/10.12688/F1000RESEARCH.19544.2
Mullany, L. C., Darmstadt, G. L., & Tielsch, J. M. (2006). Safety and impact of chlorhexidine antisepsis interventions for improving neonatal health in developing countries. In Pediatric Infectious Disease Journal (Vol. 25, Issue 8, pp. 665–675). NIH Public Access. https://doi.org/10.1097/01.inf.0000223489.02791.70
Muriuki, A., Obare, F., Ayieko, B., Matanda, D., Sisimwo, K., & Mdawida, B. (2017). Healthcare providers’ perspectives regarding the use of chlorhexidine gel for cord care in neonates in rural Kenya: Implications for scale-up. BMC Health Services Research, 17 (1), 305. https://doi.org/10.1186/s12913-017-2262-8
Muthwii. (2017). Factors Associated with Severity of Neonatal Sepsis During Admission in Kenyatta National Hospital Paediatric Wards, Kenya: A Descriptive Cross-Sectional Study. East African Medical Journal.
Ranjeva, S. L., Warf, B. C., & Schiff, S. J. (2018). Economic burden of neonatal sepsis in sub-Saharan Africa. BMJ Global Health, 3 (1). https://doi.org/10.1136/bmjgh-2017-000347
Sankar, M. J., Chandrasekaran, A., Ravindranath, A., Agarwal, R., & Paul, V. K. (2016). Umbilical cord cleansing with chlorhexidine in neonates: A systematic review. In Journal of Perinatology (Vol. 36, Issue S1, pp. S12–S20). Nature Publishing Group. https://doi.org/10.1038/jp.2016.28
Stewart, D., Benitz, W., Watterberg, K. L., Cummings, J. J., Benitz, W. E., Eichenwald, E. C., Poindexter, B. B., Stewart, D. L., Aucott, S. W., Goldsmith, J. P., Puopolo, K. M., Wang, K. S., Raju, T. N. K., Barfield, W. D., Keels, E. L., Lacaze, T., Mascola, M., & Couto, J. R. (2016). Umbilical cord care in the newborn infant. Pediatrics, 138 (3). https://doi.org/10.1542/peds.2016-2149
UNICEF. (2019). Neonatal mortality - UNICEF DATA. Unicef. https://data.unicef.org/topic/child-survival/neonatal-mortality/
WHO. (2019). WHO | Neonatal mortality rate (per 1000 live births). http://web.archive.org/web/20111004205533/http://www.who.int/whosis/indicators/compendium/2008/4mrn/en/index.html
Zaman, S. Bin, Siddique, A. B., Ruysen, H., Kc, A., Peven, K., Ameen, S., Thakur, N., Rahman, Q. S. U., Salim, N., Gurung, R., Tahsina, T., Rahman, A. E., Coffey, P. S., Rawlins, B., Day, L. T., Lawn, J. E., & Arifeen, S. El. (2021). Chlorhexidine for facility-based umbilical cord care: EN-BIRTH multi-country validation study. BMC Pregnancy and Childbirth, 21 (1), 239. https://doi.org/10.1186/s12884-020-03338-4
Copyright (c) 2022 Yvonne Opanga, Sarah Karanja, Zena Abdullahi, Richard Gichuki, Aneesa Ahmed, Viola Tupeiya, Daniel Omolo, Happiness Oruko, Mercy Mutua, Samuel Muhula, Elizabeth Wala, Dorcas Indalo
This work is licensed under a Creative Commons Attribution 4.0 International License.
