Delivery, immediate newborn and cord care practices in Pemba Tanzania: a qualitative study of community, hospital staff and community level care providers for knowledge, attitudes, belief systems and practices

Knowledge and use of chorhexidine gel in umbilical cord care among postpartum women at Poly General Hospital, Enugu, Southeast Nigeria: a cross-sectional study

BACKGROUND

Sepsis in the first week or two of life is a major cause of newborn deaths. People from diverse cultural backgrounds use different substances for umbilical cord care. Evidence-based umbilical cord care practices have a large potential to lower infant morbidity and mortality linked to infection. This study investigated the knowledge and use of chlorhexidine gel for umbilical cord care.

METHODS

A cross-sectional descriptive survey was employed among 191 postpartum women at the Poly General Hospital Asata, Enugu, selected through simple random sampling. A researcher-developed questionnaire was used for data collection.

RESULTS

More than one-half (n=101; 52.1%) had poor knowledge of chlorhexidine gel use in umbilical cord care. There was no significant association between educational status and knowledge of chlorhexidine gel use in umbilical cord care among the participants (p=0.072). Only 89 (46.6%) had ever used chlorhexidine gel for umbilical cord care, while 49 (25.7%) used chlorhexidine gel for their last child. Parity was not significantly associated with the use of chlorhexidine gel (p=0.736). Both educational status (p=0.019) and knowledge of chlorhexidine use for umbilical cord care (p<0.001) were found to be significantly associated with its use.

CONCLUSIONS

There was poor knowledge of chlorhexidine gel use for umbilical cord care among the participants. Use of chlorhexidine gel in this population is still suboptimal. Healthcare providers should continue to provide information on chlorhexidine gel use in umbilical cord care in order to optimise its knowledge and use. Other factors associated with the use of chlorhexidine gel for umbilical cord care should be explored.

Level of Knowledge on Kangaroo Mother Care and Its Associated Factors Among Postnatal Mothers With Preterm Babies in Central Tanzania: Hospital-Based Cross-Sectional Study

Introduction

Kangaroo mother care (KMC) has been proven to reduce preterm babies' deaths by 40%. The study aimed at assessing the prevalence and predictors of knowledge about KMC among postnatal mothers of preterm babies in the Central zone, Tanzania.

Objective

To assess the level of knowledge about KMC and its associated factors.

Methods

It was an analytical cross-sectional study involving 363 mothers of preterm babies from the Central zone. All mothers admitted during data collection and who met the inclusion criteria were enrolled until the sample size was attained. A structured questionnaire was used for data collection. Data were analyzed using SPSS v23. Descriptive statistics were used to describe the study variable while inferential statistics (univariate and multivariate analyses) were used to determine the predictors of knowledge.

Results

Only 138(38%) postnatal mothers had adequate knowledge about KMC. Factors associated with knowledge on KMC were the age of the mother (those aged ≥30 years were almost four times more likely to have adequate knowledge compared to those aged <20 years [P  =  .044]), level of education of the mother (women who had secondary education and above were six times more likely to have adequate knowledge on KMC compared with those with no formal education [P < .001) and the family type of a postnatal mother living in (those living in a nuclear families were 48% less likely to have adequate knowledge if compared with those living in extended families [P  =  .012]).

Conclusion

Less than half of the interviewed postdelivery women had adequate knowledge of KMC. Postdelivery women who were more likely to have adequate knowledge about KMC were those aged more than 30 years, with a higher level of education, and living in extended families. We recommend a deliberate effort on improving postnatal mothers' knowledge of KMC, one of the strategies being initiating care of preterm babies in the antenatal package to prepare these mothers.

Prevalence of essential newborn care in home and facility births in the Peruvian Amazon: analysis of census data from programme evaluation in three remote districts of the Loreto region

Background

Essential newborn care (ENC) covers optimal breastfeeding, thermal care, and hygienic cord care. These practices are fundamental to save newborn lives. Despite neonatal mortality remaining high in some parts of Peru, no comprehensive data on ENC is available. We sought to estimate the prevalence of ENC and assess differences between facility and home births in the remote Peruvian Amazon.

Methods

We used baseline data from a household census of rural communities of three districts in Loreto region, collected as part of the evaluation of a maternal-neonatal health (MNH) programme. Women between 15 and 49 years with a live birth in the last 12 months were invited to complete a questionnaire about MNH-related care and ENC. Prevalence of ENC was calculated for all births and disaggregated by place of birth. Adjusted prevalence differences (PD) were post-estimated from logistic regression models on the effect of place of birth on ENC.

Findings

All 79 rural communities with a population of 14,474 were censused. Among 324 (>99%) women interviewed, 70% gave birth at home, most (93%) without skilled birth assistance. Among all births, prevalence was lowest for immediate skin-to-skin contact (24%), colostrum feeding (47%), and early breastfeeding (64%). ENC was consistently lower in home compared to facility births. After adjusting for confounders, largest PD were found for immediate skin-to-skin contact (50% [95% CI: 38-62]), colostrum feeding (26% [16-36]), and clean cord care (23% [14-32]). ENC prevalence in facilities ranged between 58 and 93%; delayed bathing was lower compared to home births (-19% [-31 to -7]).

Interpretation

Low prevalence of ENC practices among home births in a setting with high neonatal mortality and difficult access to quality care in facilities suggests potential for a community-based intervention to promote ENC practices at home, along with promotion of healthcare seeking and simultaneous strengthening of routine facility care.

Funding

Grand Challenges Canada and Peruvian National Council of Science, Technology, and Technology Innovation.

Effect of a supportive-educative nursing intervention programme on knowledge of chlorhexidine gel for umbilical cord management amongst mothers in Cross River State, Nigeria

BACKGROUND

Umbilical cord infection contributes significantly to neonatal mortality rate in sub-Saharan Africa. Studies have shown low knowledge of chlorhexidine (CHX) gel for umbilical cord management amongst mothers in low-resource settings, including Nigeria.

OBJECTIVE

The objective of this study was to assess the effectiveness of a supportive-educative nursing intervention programme on knowledge of CHX gel amongst mothers in Cross River State, Nigeria.

METHODS

A quasi-experimental study design was used, and study participants comprised 168 expectant mothers, who were purposely selected and assigned to randomised control and intervention groups. The instrument for data collection was a researcher-developed structured questionnaire. The data were analysed using Statistical Package for Social Sciences version 23 for descriptive and inferential statistics at significant level was set at p 0.05.

RESULTS

The result showed that at post-test the knowledge score of mothers on CHX gel improved significantly in the intervention group (t 77 = 24.394; p 0.05). The result showed no significant difference between mothers' demographic variables and knowledge of CHX gel.

CONCLUSION

A supportive-educative nursing intervention programme could effectively improve knowledge of CHX gel for umbilical cord management amongst mothers. This underscores the need to improve mothers' knowledge of CHX gel by healthcare personnel.

Factors Influencing Neonatal Practice in a Rural Community in Kano (Northern), Nigeria

Nigeria has the highest number of neonatal and under-five deaths in Africa. Socio-cultural determinants play an important role in disease burden in low-middle income countries. This study aimed to describe knowledge, attitudes and neonatal care practice among household caregivers in a rural community in Nigeria, specifically uvulectomy, female genital mutilation (FGM), failure to routinely immunize and unsafe cord care. Further, relationships between demographic characteristics and knowledge, attitudes and neonatal care practices among caregivers were analyzed. The study design was descriptive correlational and cross-sectional. Consented caregivers (N = 298) were enrolled and interviewed using a structured questionnaire. Data were collected on demographic characteristics of the study participants and practice of uvulectomy, FGM, immunization and cord care. Statistically significant correlations were found between the practice of uvulectomy, FGM and failure to immunize based on occupation (p = 0.0202, p = 0.0290, p = 0.0071) and educational level (p =< 0.0001, p =< 0.0001, p =< 0.0001), with variations by ethnicity. Intense, preventative health measures and maternal education to eliminate harmful care practices are essential to influence outcomes.

Integrated review of healthcare provider postnatal newborn care recommendations in Sub-Saharan Africa

AIMS

To (1) identify formal and informal healthcare provider knowledge and counselling on newborn care recommendations; (2) identify care guidelines used; and (3) determine healthcare provider training regarding recommendations.

BACKGROUND

In sub-Saharan Africa, many newborn deaths occur in the community between days two to 42 of life.

INTRODUCTION

Formal and informal healthcare providers, including nurses and community health workers, counsel newborn caregivers but little is known about their recommendations.

METHODS

Integrative review of studies conducted 2000-2018 after search of PubMed, CINAHL, Embase, and African healthcare journals. Study quality was assessed and findings synthesized.

FINDINGS

Twelve qualitative, quantitative, or mixed-methods studies (quality good to poor) from seven countries were included. Eleven reported on one to three recommendations; one study reported on eight recommendations. Knowledge or counselling on feeding, cord care, recognizing illness, referrals, informal treatment, home visits, immunizations, follow-up examinations, thermal care, low birthweight, and bed net usage were reported. Formal healthcare providers gave recommendations in only two studies. Four studies documented use of guidelines. Six studies reported on training.

DISCUSSION

Studies were primarily descriptive, limiting quality. Feeding and cord care recommendations were prioritized. Care guidelines were underutilized. Additional training on recommendations is needed. These findings regarding healthcare providers align with other regions with high neonatal mortality.

CONCLUSION

Research is needed to improve and sustain knowledge, counselling, and guideline usage among providers to address neonatal mortality.

IMPLICATIONS FOR NURSING

The unique role of nurses to promote newborn health appears under-researched. Nurse professionalization and specialization may contribute to sustained knowledge of and counselling on newborn recommendations.

IMPLICATIONS FOR HEALTH POLICY

As countries adopt universal health care, policies that enable formal providers to encourage maternal-newborn engagement in newborn health promotion before transition to the community are needed. Collaboration between formal and informal providers may improve dissemination of recommendations and contribute to gains in newborn health.

A qualitative exploration of the sociocultural determinants of exclusive breastfeeding practices among rural mothers, North West Nigeria

Background

Suboptimal breastfeeding is responsible for 96% of deaths among children under 12 months of age in developing countries. However, the exclusive breastfeeding rate in Nigeria from birth to 6 months is just 23%. The study explored the sociocultural factors that influence exclusive breastfeeding among rural mothers.

Methods

The social constructionism-interpretivist epistemological approach underpinned this qualitative study. Semi-structured interviews were conducted with 20 mothers aged 18–39 years, purposefully sampled from two Local Government Areas in Katsina State, Nigeria. Thematic content approach was utilised for analysis.

Results

Three major themes were developed from the analysis: (1) Breastfeeding initiation – the determinants of how soon a mother initiated breastfeeding included traditional new-born care practices, the birth attendant and place of delivery. (2) Exclusive breastfeeding - motivation to sustain exclusive breastfeeding was influenced by the conflict between the obligation to perform traditional rites, the mother’s awareness and family support. (3) Decision-making about infant feeding – the husband, grandmother, traditional birth attendant and the health workers all influenced participants’ decisions around infant feeding. Despite awareness of the benefits of exclusive breastfeeding among most mothers interviewed, they expressed concerns that they may not win their family’s support if their views were contrary to those held by other family members.

Conclusion

While mothers have limited powers to make decisions, the key role that grandmothers and husbands have in decisions about breastfeeding demonstrates the need to engage the support of partners and relatives through community-driven policies and integrated interventions that address social and cultural barriers throughout the prenatal and postnatal period.

Trends, determinants, and newborn mortality related to thermal care and umbilical cord care practices in South Asia

BACKGROUND

Although child mortality has decreased over the last several decades, neonatal mortality has declined less substantially. In South Asia, neonatal deaths account for the majority of all under-five deaths, calling for further study on newborn care practices. We assessed five key practices: immediate drying and wrapping, delayed bathing, immediate skin-to-skin contact after birth, cutting the umbilical cord with a clean instrument, and substances placed on the cord.

METHODS

Using data from Demographic and Health Surveys conducted in Bangladesh, India, and Nepal between 2005 and 2016, we examined trends in coverage of key practices and used multivariable logistic regression to analyze predictors of thermal care and hygienic cord care practices and their associations with neonatal mortality among home births. The analysis excluded deaths on the first day of life to ensure that the exposure to newborn care practices would have preceded the outcome. Given limited neonatal mortality events in Bangladesh and Nepal, we pooled data from these countries.

RESULTS

We found that antenatal care and skilled birth attendance was associated with an increase in the odds of infants' receipt of the recommended practices among home births. Hygienic cord care was significantly associated with newborn survival. After controlling for other known predictors of newborn mortality in Bangladesh and Nepal, antiseptic cord care was associated with an 80% reduction in the odds of dying compared with dry cord care. As expected, skilled care during pregnancy and birth was also associated with newborn survival. Missing responses regarding care practices were common for newborns that died, suggesting that recall or report of details surrounding the traumatic event of a loss of a child may be incomplete.

CONCLUSIONS

This study highlights the importance of maternal and newborn care and services for newborn survival in South Asia, particularly antenatal care, skilled birth attendance, and antiseptic cord care.

Determinants of adverse neonatal outcomes among postnatal women in Dar es Salaam -Tanzania

BACKGROUND

Neanatal comploications are the commonest problems facing babies in Tanzania. An attempt has been made to investigate determinants of neonatal outcomes among postnatal women.

METHODS

Using a case-contrrol study design, 165 women were selected from 3 health facilities, where they had had antenatal care (ANC), labour, delivery and post natal care.

RESULTS

Chi- square test revealed that gestational age (p-value, 0.01), HIV status (p-value, 0.000) and malaria (p-value, 0.001<0.05) were significantly associated with adverse neonatal outcomes.

CONCLUSION

The study concluded that implementation of community-based intervention is needed to ensure survival of newborns.

Can community health workers identify omphalitis? A validation study from Southern Province, Zambia

OBJECTIVE

Omphalitis, or umbilical cord infection, is an important cause of newborn morbidity and mortality in low-resource settings. We tested an algorithm that task-shifts omphalitis diagnosis to community-level workers in sub-Saharan Africa.

METHODS

Community-based field monitors and Zambian paediatricians independently evaluated newborns presenting to health facilities in Southern Zambia using a signs and symptoms checklist. Responses were compared against the paediatrician's gold standard clinical diagnosis.

RESULTS

Of 1009 newborns enrolled, 6.2% presented with omphalitis per the gold standard clinical diagnosis. Paediatricians' signs and symptoms with the highest sensitivity were presence of pus (79.4%), redness at the base (50.8%) and newborn flinching when cord was palpated (33.3%). The field monitor's signs and symptoms answers had low correlation with paediatrician's answers; all signs and symptoms assessed had sensitivity <16%.

CONCLUSION

Despite extensive training, field monitors could not consistently identify signs and symptoms associated with omphalitis in the sub-Saharan African setting.

Effectiveness of a campaign to implement chlorhexidine use for newborns in rural Haiti

Background

Chlorhexidine topical cord application is recommended to prevent umbilical cord infections in newborns delivered at home in low-resource settings. A community campaign introducing chlorhexidine for the first time in Haiti was developed. Traditional birth attendants (TBAs) were identified as implementers since they typically cut newborns’ cords. TBAs were trained to apply chlorhexidine to the cord and demonstrate this procedure to the mother. Concurrently TBAs explained reasons for using chlorhexidine exclusively instead of traditional cord care practices. The campaign’s effectiveness was evaluated 7–10 days post-delivery using a survey administered by community health workers (CHWs) to 198 mothers.

Results

Nearly all mothers heard about chlorhexidine use and applied it as instructed. Most mothers did not initially report using traditional cord care practices. With further probing, the majority reported covering the cord but few applied an unhygienic substance. No serious cord infections were reported.

Conclusion

The campaign was highly successful in reaching mothers and achieving chlorhexidine use. In this study, the concomitant use of traditional cloth coverings or bindings of the cord did not appear harmful; however more research is needed in this area. This campaign provides a model for implementing chlorhexidine use, especially where trained TBAs and CHWs are present.

Persisting demand and supply gap for maternal and newborn care in eastern Uganda: a mixed-method cross-sectional study

Background

The slow progress in reducing maternal and newborn death in low and middle-income countries is attributed to both demand and supply-side factors. This study assessed the changes in maternal and newborn services in health facilities as well as demand for maternal and newborn health services in Eastern Uganda.

Methods

The health assessment data were collected in August 2013 and September 2015 in the districts of Kamuli, Pallisa, and Kibuku. We purposively collected data on the availability of services from 40 health facilities that provided maternal and newborn services. In addition, we conducted 24 focus group discussions (FGDs) with women and men; and 18 key informant interviews (KIs) with health workers.

Results

On the supply side, most health facilities persistently lacked lifesaving medicines such as misoprostol, IV Ampicillin, IV Gentamycin, IV Metronidazole, Magnesium Sulphate, Ergometrine, Corticosteroids, ferrous Sulphate, Folic Acid, Combined ferrous, Benzyl penicillin, and Diazepam (IM or IV). Basic newborn equipment such as stethoscope, fetal scope, working baby scale, newborn suction devices, newborn resuscitation device, and thermometer were persistently not available in most of the health facilities. Binders for Kangaroo Mother Care, blanket to wrap newborn, baby warmer or heat lamp were persistently not available in at least 80% of the health facilities. Other equipment for the management of labor and abortions such as Manual vacuum aspirator for abortion care, blank partographs and vacuum extractor were not available in most of the health facilities including referral facilities at baseline and follow-up. On the demand side, the qualitative interviews exposed long distances and inadequate transport to the health facilities, inadequate information, poverty, and poor services at the health facilities as major factors that impede women to utilize/access maternal and newborn services.

Conclusion

There are distinct influences on both demand and supply side, which restrain both health care uptake and its quality. The frequent disparity between the health facility readiness to provide services and the women readiness to utilize them needs to be addressed as the country intensifies its efforts to reduce maternal and newborn deaths through boosting facility deliveries.

Qualitative Studies of Infant and Young Child Feeding in Lower-Income Countries: A Systematic Review and Synthesis of Dietary Patterns

Continued high rates of both under- and over-nutrition in low- and low-middle-income countries highlight the importance of understanding dietary practices such as early and exclusive breastfeeding, and dietary patterns such as timely, appropriate complementary feeding-these behaviors are rooted in complex cultural ecologies. A systematic review and synthesis of available qualitative research related to infant and young child dietary patterns and practices from the perspective of parents and families in low income settings is presented, with a focus on barriers and facilitators to achieving international recommendations. Data from both published and grey literature from 2006 to 2016 was included in the review. Quality assessment consisted of two phases (Critical Appraisal Skills Program (CASP) guidelines and assessment using GRADE-CERQual), followed by synthesis of the studies identified, and subsequent thematic analysis and interpretation. The findings indicated several categories of both barriers and facilitators, spanning individual and system level factors. The review informs efforts aimed at improving child health and nutrition, and represents the first such comprehensive review of the qualitative literature, uniquely suited to understanding complex behaviors leading to infant and young child dietary patterns.

Sociocultural factors affecting uptake of home-based neonatal thermal care practices in Africa: A qualitative review

Neonatal hypothermia is a major contributor to neonatal mortality in sub-Saharan Africa, often as a comorbidity of severe infections, preterm births or asphyxia. Simple, cost-effective thermal care practices (TCPs) immediately at birth and in the post-natal period are recommended in the World Health Organization 'warm chain'. Current practices are suboptimal in the home in low-resource settings, where approximately half of neonatal deaths occur. Several databases (PubMed, OVID SP, Web of Science, The Cochrane Library and Google Scholar) were searched for original research on home-based TCPs. Seventeen articles were identified, and the results were analysed using a 'thermal care behavioural model'. This review of the qualitative literature on home-based practices across Africa illuminates the sociocultural factors affecting the uptake of recommended practices and strategies for behaviour change. Findings from the review confirm that potentially harmful cultural norms and traditions influence the sequence of TCPs in different contexts across Africa. Furthermore, caregiver factors and contextual barriers or facilitating factors to TCPs and behaviour change exist. Hypothermia and home-based TCPs are areas for further research. Thermal care behaviour change interventions tailored to the sociocultural context are necessary to improve neonatal outcomes in Africa.

Health care providers' perspectives regarding the use of chlorhexidine gel for cord care in neonates in rural Kenya: implications for scale-up

Background

This paper explores the perspectives of health care providers regarding the use of 7.1% Chlorhexidine Digluconate (CHX) gel that releases 4% chlorhexidine for newborn umbilical cord care under a managed access program (MAP) implemented in Bungoma County of Kenya. Understanding the perspectives of providers regarding CHX is important since they play a key role in the health system and the fact that their views could be influenced by prior beliefs and inconsistent practices regarding umbilical cord care.

Methods

Data are from in-depth interviews conducted between April and June 2016 with 39 service providers from 21 facilities that participated in the program. The data were transcribed, typed in Word and analyzed for content. Analysis entailed identifying recurring themes based on the interview guides.

Results

Use of CHX gel for cord care in neonates was acceptable to the health care providers, with all of them supporting scaling up its use throughout the country. Their views were largely influenced by positive outcomes of the medication including fast healing of the cord as reported by mothers, minimal side effects, reduced newborn infections based on what their records showed and mothers’ reports, ease of use that made it simple for them to counsel mothers on how to apply it, positive feedback from mothers which demonstrated satisfaction with the medication, and general acceptance of the medication by the community. They further noted that successful scale-up of the medication required community sensitization, adequate follow-up mechanisms to ensure mothers use the medication correctly, addressing issues of staffing levels and staff training, developing guidelines and protocols for provision of the medication, adopting appropriate service delivery approaches to ensure all groups of mothers are reached, and ensuring constant supply of the medication.

Conclusion

Use of CHX gel for cord care in neonates is likely to be acceptable to health care workers in settings with high prevalence of neonatal morbidity and mortality arising from cord infections. In scaling up the use of the medication in such settings, some of the health systems requirements for successful roll-out can be addressed by programs while others are likely to be a persistent challenge.

Umbilical cord-care practices in low- and middle-income countries: a systematic review

Background

Neonatal sepsis is the third leading cause of deaths for infants in their first month of life. The newly cut umbilical cord can be a pathway for bacteria that can cause newborn sepsis and death. Optimal umbilical cord care practices for newborns and during the first week of life, especially in settings with poor hygiene, has the potential to avoid these preventable neonatal deaths. The purpose of this review of cord care practices is to assist in the development of behavior-change strategies to support introduction of novel cord-care regimens, particularly 7.1% chlorhexidine digluconate for umbilical cord care.

Methods

We searched domestic and international databases for articles that were published in English between January 1, 2000, and August 24, 2016. We found 321 articles and reviewed 65 full-text articles using standardized inclusion criteria. The primary criteria for inclusion was a description of substances applied to the umbilical cord stump in the days following birth.

Results

We included 46 articles in this review of umbilical cord-care practices. Articles included data from 15 low- and middle-income countries in sub-Saharan Africa (8 countries), Asia (5 countries), North Africa (1 country), and Latin America and the Caribbean (1 country). Findings from this review suggest that documentation of cord-care practices is not consistent throughout low- and middle-income countries, yet existing literature depicts a firm tradition of umbilical cord care in every culture. Cord-care practices vary by country and by regions or cultural groups within a country and employ a wide range of substances. The desire to promote healing and hasten cord separation are the underlying beliefs related to application of substances to the umbilical cord. The frequency of application of the substance (either the number of days or the number of times per day the substance was applied), and source and cost of products used is not well-characterized.

Conclusions

This desire to actively care for the umbilical cord of a newborn—as noted in the variety of cord care practices and beliefs identified in this review—points toward the need to contextualize any behavior change approach to align with the local culture.

Electronic supplementary material

The online version of this article (doi:10.1186/s12884-017-1250-7) contains supplementary material, which is available to authorized users.

Use of antiseptic for cord care and its association with neonatal mortality in a population-based assessment in Bihar State, India

OBJECTIVES

Dry cord care is recommended for all births by the Health Ministry in India. We report prevalence of antiseptic cord care in the context of neonatal mortality in the Indian state of Bihar.

DESIGN

Population-based cross-sectional study with multistage stratified random sampling.

SETTING

Households in 1017 clusters in Bihar.

PARTICIPANTS

A representative sample of 12 015 women with a live birth in the last 12 months were interviewed from all 38 districts of Bihar (90.7% participation) in 2014.

PRIMARY AND SECONDARY OUTCOME MEASURES

Use of antiseptic cord care at birth and its association with neonatal mortality using multiple logistic regression.

RESULTS

Topical application of any material on cord was reported by 6534 women (54.4%; 95% CI 53.5% to 55.3%). Antiseptic cord care prevalence was 49.7% (95% CI 48.8% to 50.6%), the majority of which was gentian violet (76.4%). The odds of antiseptic use for cord care were higher in facility births (OR 1.46; 95% CI 1.27 to 1.69) and for deliveries by a qualified health provider (OR 1.44; 95% CI 1.26 to 1.66), but were lower for births that occurred before the expected delivery date (OR 0.77; 95% CI 0.61 to 0.96). A total of 256 (2.1%) newborns died during the neonatal period. The odds of neonatal death were significantly higher for live births with no reported antiseptic use (OR 1.53; 95% CI 1.18 to 1.99), and this association persisted when live births in health facilities were considered separately.

CONCLUSIONS

Even though dry cord care is recommended by health authorities in India, half the women in this study reported use of antiseptic for cord care mainly with gentian violet; and its use had beneficial effect on neonatal mortality. These findings suggest that the application of readily available gentian violet for cord care in less developed settings should be assessed further for its potential beneficial influence on neonatal mortality.

Trial of improved practices approach to explore the acceptability and feasibility of different modes of chlorhexidine application for neonatal cord care in Pemba, Tanzania

Background

Infections are responsible for 30–40 % of 4 million neonatal deaths annually. Use of chlorhexidine (CHX), a broad-spectrum topical antiseptic with strong residual activity, for umbilical cord cleansing has been shown to reduce infections during the neonatal period. However, the challenge remains with regard to selection of best mode of CHX delivery. As a part of formative research, we undertook a qualitative study in Pemba Island as a pilot to explore the attitudes; beliefs and practices of the community and health workers related to delivery, newborn and cord care. During the second phase of formative research, we used Trials of Improved Practices (TIPs) methodology to explore the acceptance and impediments, for the three possible modes of chlorhexidine application- 100 ml bottle with cotton swab, 10 ml single use dropper bottle and 3 g single application squeeze tube containing gel, as an umbilical cord care intervention.

Methods

In this pilot study, 204 mother-newborn pairs were enrolled from hospital and community setting in Pemba, Tanzania using a randomized three period crossover design. Mothers/guardians, Trained Birth Attendants (TBA)/ medical staff and community health workers (CHWs) were requested to try three different modes of CHX application for cord cleaning. All participants were demonstrated the method of cord cleaning using all three modes of delivery; each delivery mode was used for 3 days and an interview was conducted on day 10 to collect summary of their experience. Acceptance and preference scores were calculated based on feedback from the participants.

Results

Of 204 mother-newborn pairs, 27 were lost to follow up. 177 mothers performed the intervention and applied CHX to the newborn cord for all 9 days. Mothers rated 10 ml dropper bottle (49.7 %) as most convenient in terms of ease and application. They selected 10 ml dropper bottle (44.6 %) as their first choice; gel tube (33.9 %) and 100 ml bottle (21.5 %) as their second and third choice. TBAs, medical staff and CHWs also preferred 10 ml dropper bottle (43.3 %) over 100 ml bottle (12.9 %) and gel (38.8 %).

Conclusions

Overall acceptability of CHX application for cord cleansing was high. 10 ml single use dropper bottle was given highest preference for CHX application. An understanding of the attitudes, beliefs and cultural practices in the community and selection of the most acceptable mode of CHX delivery is essential to the design and implementation of the intervention trials examining the efficacy of CHX cord care in reducing neonatal mortality and subsequent implementation in the programs.

Trial registration

ClinicalTrials.gov NCT01528852 Registered February 3, 2012

Evaluating time between birth to cry or bag and mask ventilation using mobile delivery room timers in India: the NICHD Global Network's Helping Babies Breathe Trial

BACKGROUND

The Golden Minute®, the first minute following birth of a newborn, is a critical period for establishing ventilation after delivery, as emphasized in the Helping Babies Breathe® and other resuscitation training programs. Previous studies have reinforced training through observers' evaluation of this time period; although observation is useful for research, it may not be a sustainable method to support resuscitation practice in low-resource settings where few birth attendants are available. In order to reinforce resuscitation within The Golden Minute®, we sought to develop a simple mobile delivery-room timer on an Android cell phone platform for birth attendants to use at the time of delivery.

METHODS

We developed and evaluated a mobile delivery room timer to document the time interval from birth to the initiation of newborn crying/spontaneous respiration or bag and mask ventilation in a convenience sample of women who delivered in five hospitals in Karnataka, India. The mobile delivery room timer is an Android cell phone-based application that recorded key events including crowning, delivery, and crying/spontaneous respiration or bag and mask ventilation. The mobile delivery room timer recorded the birth attendant verbally indicating the time of crowning, birth-(defined as when the entire baby was delivered), crying/spontaneous respiration or bag and mask ventilation. The mobile delivery room timer results were validated in a subsample by a trained observer (nurse) who independently recorded the time between delivery and initiation of crying/spontaneous respiration or bag and mask ventilation.

RESULTS

Of the total 4,597 deliveries, 2,107 (46%) were timed; a sample (n = 438) of these deliveries was also observed by a trained nurse. There was high concordance between the mobile delivery room timer and observed time elapsed between birth and crying/spontaneous respiration or ventilation (correlation =0.94, p < 0.0001). The majority of neonates in both groups cried/breathed spontaneously or received bag and mask ventilation by 1 min (430/438 by the timer vs. 433/438 for observer).

CONCLUSIONS

We demonstrated that a simple mobile delivery room timer application was feasible to use during delivery and provided valid observations of the time to crying/spontaneous respiration or bag and mask ventilation. This type of tool may be useful in reinforcing neonatal resuscitation training and the need to ensure spontaneous or assisted ventilation by The Golden Minute®.