Chlorhexidine cord care after a national scale-up as a newborn survival strategy: A survey in four regions of Ethiopia

  • PLoS ONE, Volume 17, No. 8 August, Year 2022

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Study Justification:
– Chlorhexidine cord care is an effective intervention to reduce neonatal infection and death in resource-constrained settings.
– The Federal Ministry of Health of Ethiopia adopted chlorhexidine cord care in 2015, with national scale-up in 2017.
– However, there is a lack of evidence on the provision of this important intervention in Ethiopia.
– This study aims to fill this knowledge gap by reporting on the coverage and determinants of chlorhexidine cord care for newborns in Ethiopia.
Study Highlights:
– Overall, chlorhexidine was reportedly applied to the umbilical cord at some point postpartum among 46.1% of all newborns.
– Chlorhexidine cord care started within 24 hours after birth for 34.4% of newborns, with significant regional variation.
– Among the newborns who received chlorhexidine cord care, 48.3% received it for the recommended seven days or more.
– Neonates whose birth was assisted by skilled birth attendants had more than ten times higher odds of receiving chlorhexidine cord care.
– Neonates born to mothers with knowledge of the benefit of chlorhexidine cord care had significantly higher odds of receiving chlorhexidine cord care.
Study Recommendations:
– Efforts must continue to ensure women can reach skilled care at delivery.
– Efforts must be made to ensure adequate care for newborns who do not yet access skilled delivery.
– Awareness campaigns should be conducted to educate mothers about the benefits and proper duration of chlorhexidine cord care.
Key Role Players:
– Federal Ministry of Health of Ethiopia
– Regional health authorities
– Health care providers
– Community health workers
– Non-governmental organizations (NGOs) working in maternal and newborn health
Cost Items for Planning Recommendations:
– Training and capacity building for health care providers
– Awareness campaigns and educational materials for mothers
– Monitoring and evaluation activities
– Supplies and equipment for chlorhexidine cord care
– Coordination and management costs

The strength of evidence for this abstract is 7 out of 10.
The evidence in the abstract is moderately strong, but there are some areas for improvement. The study provides specific data on the coverage and determinants of chlorhexidine cord care in four regions of Ethiopia, which adds to the existing knowledge on the topic. The study design, a standardized survey using a multistage cluster sampling approach, is appropriate for the research question. The sample size of 1020 women is adequate for estimating key variables and analyzing determinants. The use of complex data analysis methods, such as complex sample multivariable logistic regression, strengthens the analysis. However, there are some limitations to consider. The study relies on self-reported data from mothers, which may introduce recall bias. The study does not provide information on the representativeness of the sample and the response rate, which could affect the generalizability of the findings. Additionally, the study does not discuss potential confounding factors that may influence the relationship between the determinants and chlorhexidine cord care. To improve the evidence, future studies could consider using objective measures of chlorhexidine cord care, such as direct observation or medical records. It would also be beneficial to include information on the representativeness of the sample and the response rate to enhance the generalizability of the findings. Finally, addressing potential confounding factors in the analysis would strengthen the conclusions of the study.

Introduction Chlorhexidine cord care is an effective intervention to reduce neonatal infection and death in resource constrained settings. The Federal Ministry of Health of Ethiopia adopted chlorhexidine cord care in 2015, with national scale-up in 2017. However, there is lack of evidence on the provision of this important intervention in Ethiopia. In this paper, we report on the coverage and determinants of chlorhexidine cord care for newborns in Ethiopia. Methods A standardized Nutrition International Monitoring System (NIMS) survey was conducted from January 01 to Feb 13, 2020 in four regions of Ethiopia (Tigray, Amhara, Oromia, and Southern Nations, Nationalities and Peoples Region [SNNPR]) on sample of 1020 women 0–11 months postpartum selected through a multistage cluster sampling approach. Data were collected using interviewer-administered questionnaires in the local languages through home-to-home visit. Accounting for the sampling design of the study, we analyzed the data using complex data analysis approach. Complex sample multivariable logistic regression was used to identify the determinants of chlorhexidine cord care practice. Results Overall, chlorhexidine was reportedly applied to the umbilical cord at some point postpartum among 46.1% (95% confidence interval [CI]: 41.1%– 51.2%) of all newborns. Chlorhexidine cord care started within 24 hours after birth for 34.4% (95% CI: 29.5%– 39.6%) of newborns, though this varied widely across regions: from Oromia (24.4%) to Tigray (60.0%). Among the newborns who received chlorhexidine cord care, 48.3% received it for the recommended seven days or more. Further, neonates whose birth was assisted by skilled birth attendants had more than ten times higher odds of receiving chlorhexidine cord care, relative to those born without a skilled attendant (adjusted odds ratio [AOR]: 10.36, 95% CI: 3.73–28.75). Besides, neonates born to mothers with knowledge of the benefit of chlorhexidine cord care had significantly higher odds of receiving chlorhexidine cord care relative to newborns born to mothers who did not have knowledge of the benefit of chlorhexidine cord care (AOR: 39.03, 95% CI: 21.45–71.04). Conclusion A low proportion of newborns receive chlorhexidine cord care in Ethiopia. The practice of chlorhexidine cord care varies widely across regions and is limited mostly to births attended by skilled birth attendants. Efforts must continue to ensure women can reach skilled care at delivery, and to ensure adequate care for newborns who do not yet access skilled delivery.

The study was conducted in four regional states of Ethiopia, viz. Tigray, Amhara, Oromia, and Southern Nations, Nationalities and Peoples Region (SNNPR) (Fig 1). As per the 2007 National Housing Census of Ethiopia, these four regions cover more than 85% of the national population [24]. The study included 12 zones (second-level of the administrative division in Ethiopia) in the four regions–three from each region: Central Tigray, East Tigray and South Tigray zones of the Tigray region; West Gojam, East Gojam and Awi zones of Amhara region; Horo-Guduru, West Wollega and East Wollega zones of Oromia region; and Hadiya, Kembata-Tembaro and Sidama zones of the SNNPR region. A total of 71 districts (third-level administrative division) and 104 villages were covered in the 12 zones in which the study was conducted. SNNPR: Southern Nations, Nationalities, and Peoples Region. Note: Currently there are two additional regions, namely Sidama and South West Ethiopia regions, which were created after the survey was conducted. The map is constructed based on shapefile obtained from open AFRICA (https://africaopendata.org/dataset/ethiopia-shapefiles; accessed on 01 February 2022). This was a community-based cross-sectional survey conducted from January 01 to Feb 13, 2020 among women 0–11 months postpartum with live birth and permanently residing in the selected villages. The survey was conducted as part of the baseline assessment for the Nutrition International’s (NI’s) Maternal, Newborn Health and Nutrition (MNHN) Programme planned to be implemented in the survey districts over 2020–2024. Promoting the use of Chlorhexidine for cord care is among the package of services included in the NI’s MNHN programme. As this study was part of a larger survey, sample size was estimated to ensure that it would be sufficient to estimate all key indicators covered by the NI-supported MNHN programme. Accordingly, a sample size of 1020 was found to be adequate for estimating all key variables. As for chlorhexidine in particular, assuming the expected proportion of chlorhexidine cord care among newborns to be 50% (to maximize the sample size) and considering a design effect of 2.0 to account for precision loss due to multistage cluster sampling, the sample size of 1020 used for the present study was sufficient to estimate the 95% confidence interval (CI) of the proportion of newborns who received chlorhexidine cord care within a margin of error of +/-4.34%. This sample size was also sufficient to analyze the determinants of chlorhexidine cord care. At the 95% confidence level and 80% power, taking the proportion of newborns who received chlorhexidine cord care in the reference categories of the determinants reported in this paper (region of residence, mother’s education, skilled attendance at birth, and mother’s knowledge of the benefit of chlorhexidine cord care) as the proportion of the outcome in the ‘unexposed group’, the sample size was adequate to detect statistically significant effects for adjusted odds ratios in the range of 1.7 to 3.0. The multistage cluster sampling approach involved the following. In the first stage, 71 districts were identified using probability proportional to size (PPS) technique from across all 12 zones. For the second stage sampling, in most of the districts, one kebele (a lower administrative unit in Ethiopia) was selected at random. Because of relatively smaller population sizes in some of the districts, in a few districts (especially in Tigray region) PPS technique resulted in selection of 2–4 kebeles 2–4 kebeles. Ultimately, one village was selected from each kebele using simple random sampling (SRS) technique. In each selected village, a home-to-home search was done to identify eligible women. The first 10 eligible women 0–11 months postpartum with live birth identified during the home-to-home search were included in the study. If a sufficient number of eligible women was not found in a village, the remaining number of women was obtained from an adjacent village in the same kebele. The dependent variable for this study was chlorhexidine cord care of neonates. It was measured as the proportion of newborns who received chlorhexidine to the umbilical stump within 24 hours of birth in the previous one year. The information on chlorhexidine use for cord care was obtained through the mothers’ self reports. A coloured picture of chlorhexidine tube was shown to the mothers to help them recall what chlorhexidine is. Various plausible maternal sociodemographic, knowledge and health care-related variables were analyzed as the determinants of chlorhexidine core care. Sociodemographic variables included maternal education and region of residence. Maternal education was categorized as no formal education, primary education, secondary education and higher education, whereas region of residence comprised of the four regions in which the survey was conducted, namely Tigray, Amhara, Oromia and SNNPR. Maternal knowledge of the benefit of chlorhexidine cord care was another independent variable. Mothers who were able to name at least one of the three benefits of chlorhexidine cord care–namely ‘it prevents infection’, ‘it keeps the area clean’, and/or ‘it prevents death’–were categorized as having at least some knowledge (yes), and mothers who could not name any of those benefits were categorized as having no knowledge (no). Mothers’ knowledge of how long to apply chlorhexidine to the umbilical stump was also included as an independent variable. Mothers who stated that chlorhexidine should be applied for seven or more days were considered as having knowledge (yes), while mothers who described the proper duration of chlorhexidine application to be less than seven days and those who couldn’t describe chlorhexidine application as a way of caring for the cord were considered as having no knowledge of the correct duration of chlorhexidine cord care (no). The health-care related variable was skilled birth attendance during the last birth (i.e., in the previous one year). Births attended by doctors/clinical officers and nurses/trained midwives were categorized as having been attended by skilled birth attendants (yes); otherwise, births were categorized as having not been attended by skilled birth attendants (no).

Based on the provided information, here are some potential innovations that could be recommended to improve access to maternal health:

1. Strengthening Skilled Birth Attendance: Promote and invest in training programs for healthcare professionals, such as doctors, clinical officers, nurses, and midwives, to ensure that more births are attended by skilled birth attendants. This can improve the likelihood of newborns receiving chlorhexidine cord care and other essential maternal health interventions.

2. Community Education and Awareness: Implement community-based education programs to raise awareness about the benefits of chlorhexidine cord care and other maternal health practices. This can help increase knowledge among mothers and caregivers, leading to higher utilization of these interventions.

3. Mobile Health (mHealth) Solutions: Develop and deploy mobile health applications or SMS-based platforms to provide information and reminders to mothers and caregivers about the importance of chlorhexidine cord care and other maternal health practices. This can help bridge the gap in knowledge and ensure consistent adherence to recommended interventions.

4. Supply Chain Strengthening: Improve the availability and accessibility of chlorhexidine and other essential maternal health supplies at healthcare facilities and community levels. This can be achieved through better supply chain management, including forecasting, procurement, storage, and distribution systems.

5. Integration of Maternal Health Services: Integrate maternal health services, including chlorhexidine cord care, with existing healthcare delivery platforms, such as antenatal care, postnatal care, and immunization programs. This can ensure that mothers and newborns have access to comprehensive care throughout the continuum of pregnancy, childbirth, and the postpartum period.

6. Public-Private Partnerships: Foster collaborations between the government, private sector, and non-governmental organizations to leverage resources, expertise, and innovation in improving access to maternal health services. This can lead to innovative approaches and sustainable solutions for addressing the barriers to accessing chlorhexidine cord care and other interventions.

It is important to note that these recommendations are based on the information provided and may need to be tailored to the specific context and needs of Ethiopia.
AI Innovations Description
Based on the study mentioned, the following recommendation can be developed into an innovation to improve access to maternal health:

1. Strengthening Skilled Birth Attendance: The study found that newborns born with skilled birth attendants had higher odds of receiving chlorhexidine cord care. Therefore, it is recommended to focus on increasing the availability and accessibility of skilled birth attendants in all regions of Ethiopia. This can be achieved by training and deploying more healthcare professionals, such as doctors, nurses, and midwives, to rural and remote areas where access to skilled birth attendants is limited.

2. Increasing Awareness and Knowledge: The study also found that mothers with knowledge of the benefits of chlorhexidine cord care were more likely to use it. To improve access to maternal health, it is important to educate and raise awareness among pregnant women and their families about the importance of chlorhexidine cord care and its benefits in preventing neonatal infections and deaths. This can be done through community-based health education programs, antenatal care visits, and mass media campaigns.

3. Integration into Maternal Health Programs: The study was conducted as part of a larger survey for the Nutrition International’s Maternal, Newborn Health and Nutrition (MNHN) Program. To improve access to maternal health, it is recommended to integrate chlorhexidine cord care into existing maternal health programs and services. This can ensure that chlorhexidine is readily available and promoted as a standard practice for cord care in healthcare facilities and communities.

4. Strengthening Supply Chain Management: To improve access to chlorhexidine cord care, it is crucial to ensure a consistent and reliable supply of chlorhexidine to healthcare facilities and communities. This can be achieved by strengthening the supply chain management system, including procurement, storage, distribution, and monitoring of chlorhexidine. Collaboration with pharmaceutical companies, government agencies, and non-governmental organizations can help in ensuring the availability and accessibility of chlorhexidine.

5. Monitoring and Evaluation: To assess the impact and effectiveness of the recommended interventions, it is important to establish a robust monitoring and evaluation system. This can involve regular data collection, analysis, and reporting on the coverage and utilization of chlorhexidine cord care, as well as the determinants and outcomes of maternal health. The findings from monitoring and evaluation can guide further improvements and adjustments in the interventions to ensure continuous progress in improving access to maternal health.
AI Innovations Methodology
Based on the information provided, here are some potential recommendations to improve access to maternal health:

1. Strengthening Skilled Birth Attendance: Promote and ensure access to skilled birth attendants during childbirth. This can be achieved through training and capacity building programs for healthcare providers, improving infrastructure and resources in healthcare facilities, and increasing awareness among pregnant women about the importance of skilled birth attendance.

2. Community-based Education and Awareness: Implement community-based education programs to raise awareness about the benefits of maternal health services, including chlorhexidine cord care. This can involve engaging community leaders, local health workers, and women’s groups to disseminate information and promote positive health-seeking behaviors.

3. Integration of Maternal Health Services: Integrate maternal health services, including chlorhexidine cord care, into existing healthcare systems. This can be done by ensuring that chlorhexidine is readily available in healthcare facilities, training healthcare providers on its proper use, and incorporating it into routine antenatal and postnatal care.

4. Mobile Health (mHealth) Solutions: Utilize mobile health technologies to improve access to maternal health information and services. This can include mobile apps or text messaging platforms that provide educational resources, appointment reminders, and access to healthcare providers for remote consultations.

To simulate the impact of these recommendations on improving access to maternal health, a methodology could include the following steps:

1. Define the indicators: Identify specific indicators that will be used to measure the impact of the recommendations, such as the proportion of women receiving skilled birth attendance, the proportion of newborns receiving chlorhexidine cord care, and the knowledge level of mothers regarding maternal health practices.

2. Data collection: Collect baseline data on the selected indicators before implementing the recommendations. This can be done through surveys, interviews, or existing data sources.

3. Intervention implementation: Implement the recommended interventions, such as training programs for healthcare providers, community-based education campaigns, or mHealth solutions.

4. Post-intervention data collection: Collect data on the selected indicators after the interventions have been implemented. This can be done using the same methods as the baseline data collection.

5. Data analysis: Analyze the pre- and post-intervention data to assess the impact of the recommendations. This can involve comparing the indicators before and after the interventions, calculating the change in proportions or knowledge levels, and conducting statistical tests to determine the significance of the changes.

6. Interpretation and reporting: Interpret the findings of the data analysis and report on the impact of the recommendations. This can include summarizing the changes in access to maternal health services, identifying any disparities or challenges that need to be addressed, and making recommendations for further improvements.

By following this methodology, policymakers and healthcare providers can gain insights into the effectiveness of the recommendations in improving access to maternal health and make informed decisions for future interventions.

Statistics:
Citations: 1
Authors: 7
Identifiers:
DOI: 10.1371/journal.pone.0271558
Research Areas:
Community Interventions, Food Security, Health System and Policy, Maternal Access, Maternal and Child Health, Quality of Care, Workforce
Study Countries:
Ethiopia
Study Design:
Case-Control Study, Cross Sectional Study, randomised-control-trial
Study Approach:
Quantitative
Participants Gender:
Female
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