Abstract
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.
Keywords: chlorhexidine gel, knowledge, postpartum women, umbilical cord care, use
Introduction
Globally, 2.5 million newborns die within the first month of life each year, accounting for 47% of all under-five mortality, with infections being the second leading cause.1 Neonatal mortality (NNM) rates are high in poor nations, particularly in sub-Saharan Africa, where Nigeria is situated.2 In sub-Saharan Africa, Nigeria accounts for one-quarter of all neonatal and child deaths.3 On a global scale, Nigeria has the highest rate of under-five fatalities.3,4 Sepsis in the first week or two of life is a major cause of newborn deaths.5,6 A study revealed that a combined 60.2% of all causes of neonatal deaths were due to sepsis (23.3%) and tetanus (13%), two prominent complications of umbilical infections.7
Adequate cord care procedures are encouraged to lower the risk of neonatal sepsis (NNS) secondary to an infected umbilical cord stump. Thus, evidence-based umbilical cord care practices are among public health opportunities with a large potential to lower infant morbidity and mortality linked to infection.8 The umbilical cord is seen as the physical and psychological connection between the mother and foetus during pregnancy. This arrangement enables the exchange of nutrients and oxygen from the mother's blood into the foetal blood while also eliminating waste materials from the foetal blood.9 The umbilical cord connects the mother and the foetus in-utero and acts as a lifeline. However, the cord is severed during delivery, and the stump may act as a conduit for systemic infections such as bacteraemia, which could lead to NNS if not adequately or appropriately cared for.10 Maternal infection, early or prolonged membrane rupture, an unhygienic delivery environment, low birth weight (2500 g) and past umbilical catheterisation are risk factors for omphalitis (cord infection), neonatal tetanus and sepsis. Staphylococcus aureus, group A Streptococcus, Escherichia coli, Klebsiella pneumonia and Proteus mirabilis are a few common pathogenic bacteria linked to this infection.11
The term ‘cord care’ describes procedures used to ease cord separation and prevent germs from colonising the newborn's umbilical stump. Reduced NNS-related mortality is possible with the best umbilical cord care procedures.12 In nations with low rates of newborn mortality, dry cord care is recommended.13 However, in nations with high rates of newborn death and poor cleanliness, the use of antiseptic chemicals is advised.14 Methylated spirit, silver sulphadiazine, gentian violet, iodine, chlorhexidine and topical antibiotics are a few examples of such antiseptics. Findings from randomised clinical trials have demonstrated that using chlorhexidine digluconate (CHX), which releases chlorhexidine for umbilical cord care, significantly reduces neonatal morbidity and mortality in high prevalence regions.2,15–16 The WHO recommends clean, dry cord care for all newborns and daily chlorhexidine gel application to the umbilical stump for the first week of life for homebirths in high NNM settings (>30 deaths/1000 live births).17 Generally, the WHO recommends a daily chlorhexidine (4%) application to the umbilical cord stump during the first week of life for newborns who are born at home in settings with a high NNM (NNM rate >30 per 1000). They also recommend clean, dry cord care for newborns born in health facilities, and at home in low NNM settings. Use of chlorhexidine in these situations may be considered only to replace application of a harmful traditional substance such as cow dung to the cord stump according to the WHO.17 In addition, different systematic reviews and meta-analyses have concluded that chlorhexidine application significantly reduces NNM.18,19
Chlorhexidine, a bisbiguanide substance, has broad-spectrum antibacterial characteristics effective against both gram-positive and gram-negative microorganisms. It is harmless to the delicate skin of newborns and damages the bacterial cell membrane, enhancing the permeability, leaking and killing of the germs.20 Chlorhexidine gel is recommended as a ‘low-cost, high-benefit intervention’ to reduce mortality, even among preterm and low birthweight neonates.21 Considering the lack of hygienic conditions at some health facilities and at home, early discharge from health facilities after birth, and possible application of harmful substances at home, the healthcare system in Nigeria has included chlorhexidine gel cord care in its ‘package of high-impact child survival interventions’ for use both at a community and health facilities level.
Traditionally, there is a general desire to actively care for the umbilical cord of newborns, as observed by the variety of cord care practices and beliefs in Nigeria.22,23 Some of these practices range from the use of olive oil to engine oil, using red toothpaste and mentholatum in the southern part of Nigeria; and herbs, salt, and even cow dung in the northern part of Nigeria,24 with the intention of promoting healing, preventing infection and/or hastening the umbilical cord separation time. These diverse cord care practices are fuelled by the quality of available information on umbilical cord care, in addition to socioeconomic and cultural factors. In Nigeria, programmes have been put into place to scale up the use of chlorhexidine.
As mentioned, the WHO advises using chlorhexidine in regions where the infant mortality rate is >30 per 1000 live births because of its demonstrated ability to minimise umbilical stump infections.25 Given its current incidence of newborn death, Nigeria falls within this group. However, in Nigeria, the use of unconventional remedies such as toothpaste, dusting powder, salt and petroleum jelly is still prevalent.14,26 Use of these substances/preparations can raise the risk of tetanus, sepsis and, ultimately, newborn mortality.
There are limited data regarding the knowledge and use of chlorhexidine gel in the study setting and Nigeria in general. However, in the two northern Nigerian states of Bauchi and Sokoto, an assessment of the trends in newborn umbilical cord care practices during 2012–2017 among households indicated that the use of chlorhexidine gel for cord care increased significantly, from 0.8% in 2012 and 9.2% in 2013 to 17.1% in 2015 in Sokoto, and from 0.7% in 2012 and 2.4% in 2013 to 21.5% in 2015 in Bauchi.27 More recently, among 199 mothers in a well-baby clinic in Rivers state, it was found that only 23.8% of the respondents knew that chlorhexidine gel prevents neonatal infections while 9.6% used it. Poor knowledge was found to correlate significantly with poor use.28 In a similar study involving 42 mothers, the results showed that 31% were aware of the recommendation favouring chlorhexidine gel for umbilical cord care, but only 23.8% had ever used chlorhexidine gel for umbilical cord care.29
In view of the enormous contributions of poor umbilical cord care practices to umbilical cord infections and neonatal morbidity and mortality, and considering the limited nature of data on the knowledge and use of chlorhexidine gel in the area of study, this study was conducted to assess the knowledge and use of chlorhexidine gel in cord care among postpartum women at Poly General Hospital Asata, Enugu, Southeast Nigeria.
Methods
The study design was a cross-sectional descriptive survey. The area of study was Poly General Hospital Asata, Enugu State, Nigeria. Poly General Hospital was formally a subdistrict hospital before it was upgraded to its current status. A sample size of 197 was calculated from a total population of 320 postpartum women using Cochrane's formula. The participants were recruited using a simple random sampling technique. A researcher-developed questionnaire validated by five professionals with expertise in measurement and evaluation, and maternal and child health, was used for data collection. A test-retest method was used to establish the reliability of the instrument among 20 postpartum mothers in Uwani General Hospital, Enugu. Data obtained were analysed using the Cronbach alpha test, which yielded a reliability coefficient of 0.89. Ethical approval was obtained from the Ethics and Research Committee of Enugu State Ministry of Health (ref: MH/MSD/REC23/34). Informed consent was sought from the participants before administration of the questionnaire. The principles of voluntary participation, anonymity and confidentiality were upheld throughout the study. An administrative permit was obtained from the hospital management prior to data collection. An explanation of the purpose of the study and necessary instructions on how to complete the questionnaire were provided before data collection. The questionnaire was administered by two research assistants on the spot. Data were analysed using both descriptive and inferential statistics. The descriptive statistics—frequency, percentage, mean and SD—were used to summarise the items of the questionnaire. An overall knowledge score was obtained for each participant by scoring and summing each correct response of the knowledge items. The knowledge score was grouped as either good (>50) or poor (≤50). For inferential statistics, the χ2 test was used to test the hypothesis at 5% level of significance. All analyses were performed with the aid of Statistical Package for Social Sciences (SPSS) version 25 (SPSS Incorporated Chicago) and Excel Software (Microsoft corporation, Washington).
Results
Demographic characteristics of postpartum women at Poly General Hospital, Enugu
The demographic characteristics of the participants are shown in Table 1. The largest proportion (41.4%, n=79) of participants belonged to the 31–35 y age group. They were mostly Christians (92.7%, n=177). Eighty-one of the participants had senior secondary education (42.4%), while 45.0% (86) were business women. About one-third (64; 33.5%) earn an average monthly allowance of Nigerian Naira 33 000–50 000 (33.5%); the place of residence was mainly urban (70.7%, n=135); a majority (176; 92.1%) were from monogamous families; 73 had three children (38.2%) and 74 had a parity of three (38.7%).
Table 1.
Demographic characteristics of postpartum women at Poly General Hospital, Enugu (n=191)
| Frequency | % | Range | M±SD | |
|---|---|---|---|---|
| Age, y | 15–40 | 31.41±4.98 | ||
| ≤25 | 22 | 11.5 | ||
| 26–30 | 57 | 29.8 | ||
| 31–35 | 79 | 41.4 | ||
| ≥36 | 33 | 17.3 | ||
| Religion | ||||
| - Islam | 14 | 7.3 | ||
| - Christianity | 177 | 92.7 | ||
| Educational status | ||||
| - Formal education | 24 | 12.6 | ||
| - Senior secondary school certificate | 81 | 42.4 | ||
| - Diploma/NCE | 28 | 14.7 | ||
| - First degree | 46 | 24.1 | ||
| - Higher degree-MSC, PHD | 12 | 6.6 | ||
| Occupation | ||||
| - Housewife | 53 | 27.7 | ||
| - Trader/business | 86 | 45.0 | ||
| - Public servant | 21 | 11.0 | ||
| - Artisan | 12 | 6.3 | ||
| - Student | 19 | 9.95 | ||
| Average monthly allowance, Nigerian Naira | ||||
| <33 000 | 62 | 32.5 | ||
| 33 000–50 000 | 64 | 33.5 | ||
| 51 000–100 000 | 37 | 19.4 | ||
| >100 000 | 28 | 14.7 | ||
| Place of residence | ||||
| - Rural area | 56 | 29.3 | ||
| - Urban area | 135 | 70.7 | ||
| Family type | ||||
| - Monogamous | 176 | 92.1 | ||
| - Polygamous | 15 | 7.9 | ||
| No. of children | ||||
| 1 | 23 | 12.0 | ||
| 2 | 54 | 28.3 | ||
| 3 | 73 | 38.2 | ||
| 4 | 25 | 13.1 | ||
| >4 | 16 | 8.4 | ||
| Parity | ||||
| 1 | 24 | 12.6 | ||
| 2 | 42 | 22.0 | ||
| 3 | 74 | 38.7 | ||
| 4 | 31 | 16.2 | ||
| >4 | 20 | 10.5 | ||
| No response | 6 | 3.1 |
The results in Table 2 show that more than one-half (116; 60%) had heard of chlorhexidine gel use in umbilical cord care. Among those who had heard about it, 83.6% correctly knew that it is an antiseptic gel for newborn umbilical cord care used to prevent infection in the child (69.0%). A majority knew that it is applied to the umbilical cord after birth (74.1%), and on both the stump and surrounding skin (52.6%). More than one-half of the participants who had heard of chlorhexidine use in umbilical cord care knew it should be applied once a day (52.6%) and for a period of ≥7 d (61.2%). A large number (83.6%) knew that handwashing is required before applying chlorhexidine gel to the umbilical cord. Among those had heard of chlorhexidine, a majority had good knowledge (77.6%). However, of all the women studied, less than one-half had good knowledge (47.1%), while a little more than one-half (52.9%, f=101) had poor knowledge of chlorhexidine gel use in umblical cord care. The results in Table 3 reveal that there is no significant association between knowledge of chlorhexidine gel and educational status of the women (p=0.072).
Table 2.
Knowledge of chlorhexidine gel in umbilical cord care among postpartum women at Poly General Hospital, Enugu (n=191)
| Frequency | % | |
|---|---|---|
| Have you heard of chlorhexidine gel? | ||
| - Yes | 116 | 60.7 |
| - No | 75 | 39.3 |
| Information source of chlorhexidine gel (n=116) | ||
| - Health professional | 69 | 59.5 |
| - Mass media | 13 | 11.2 |
| - Social media | 2 | 1.7 |
| - Friends/relatives | 32 | 27.6 |
| What is chlorhexidine gel? (n=116) | ||
| - *It is an antiseptic gel for newborn umbilical cord care | 97 | 83.6 |
| - It is a drug used to treat diarrhoea in newborns | 7 | 6.0 |
| - It is a supplement for newborns | 11 | 9.5 |
| - No response | 1 | 0.9 |
| Chlorhexidine prevents infection in the child (n=116) | ||
| - *Yes | 80 | 69.0 |
| - No | 36 | 31.0 |
| Chlorhexidine is applied to the umbilical cord after birth (n=116) | ||
| - *Yes | 86 | 74.1 |
| - No | 30 | 25.9 |
| Where is chlorhexidine gel applied? | ||
| - Stump only | 34 | 29.3 |
| - Surrounding skin only | 21 | 18.1 |
| - *Both | 61 | 52.6 |
| How often do you apply it in a day? | ||
| - *Once | 61 | 52.6 |
| - Twice | 29 | 25.0 |
| - Three times | 15 | 12.9 |
| - More than three times | 11 | 9.5 |
| How many days after birth should chlorhexidine be applied | ||
| <7 | 45 | 38.8 |
| *≥7 | 71 | 61.2 |
| Is handwashing required before applying chlorhexidine gel to the umbilical cord? | ||
| - *Yes | 97 | 83.6 |
| - No | 19 | 16.4 |
| Overall knowledge | ||
| - Good (knowledge score) | 90 | 47.1 |
| - Poor (knowledge score) | 101 | 52.9 |
indicates the correct answer to the knowledge question.
Table 3.
Association between educational status and knowledge of chlorhexidine gel among postpartum women at Poly General Hospital, Enugu
| Knowledge of chlorhexidine gel | |||||
|---|---|---|---|---|---|
| Good | Poor | Total | χ2 | p | |
| Educational status | 8.590 | 0.072 | |||
| - Formal education | 12 (50.0) | 12 (50.0) | 24 | ||
| - Senior secondary school | 33 (40.7) | 48 (59.3) | 81 | ||
| - Diploma/NCE | 13 (46.4) | 15 (53.6) | 28 | ||
| - First degree | 24 (52.2) | 22 (47.8) | 46 | ||
| - Higher degree | 6 (100.0) | 0 (0.0) | 6 | ||
From Table 4, 89 (46.9%) of participants had ever used chlorhexidine gel in umbilical cord care, while only 25.7% (49) only used chlorhexidine for umbilical cord care in their last baby. Among those who had ever used it, only 12 (13.5%) correctly used it in the first 24 h of neonatal life, about one-half used it less than 1 h after birth (51.7%), a majority (76, 85.4%) always washed their hands before using it, 44.9% applied it both to the stump and the surrounding skin, 83.1% used a finger to spread it, 76.4% kept the cord dry after applying the gel, 58.4% stopped applying it after the cord was detached, 60.7% applied the chlorhexidine gel for 7–14 d, 75.3% experienced delayed cord detachment, while 28.1% only used the gel in the hospital.
Table 4.
Use of chlorhexidine gel in umbilical cord care among postpartum women at Poly General Hospital, Enugu (n=191)
| Frequency | Percent | |
|---|---|---|
| Agent used for umbilical cord care in the last baby | ||
| - Methylated spirit only | 104 | 54.5 |
| - Chlorhexidine gel only | 49 | 25.7 |
| - Methylated spirit and chlorhexidine gel | 21 | 11.0 |
| - Others: penicillin, vaseline, cow dung, shea butter | 17 | 8.9 |
| Ever used chlorhexidine gel? | ||
| - Yes | 89 | 46.6 |
| - No | 102 | 53.4 |
| How soon after birth was chlorhexidine gel used for umbilical cord care (n=89) | ||
| <1 h | 46 | 51.7 |
| *1–23 h | 12 | 13.5 |
| 1–7 d | 30 | 33.7 |
| - No response | 1 | 1.1 |
| Always washed hands before applying chlorhexidine gel (n=89) | ||
| - *Yes | 76 | 85.4 |
| - No | 13 | 14.6 |
| Where chlorhexidine gel was applied? (n=89) | ||
| - Stump only | 29 | 32.6 |
| - Surrounding skin only | 18 | 20.2 |
| - *Both | 44 | 47.2 |
| Used a finger to spread chlorhexidine gel? (n=89) | ||
| - *Yes | 74 | 83.1 |
| - No | 15 | 16.9 |
| What was done after applying chlorhexidine gel? (n=89) | ||
| - *Keep cord dry | 73 | 82.0 |
| - Apply other agents | 16 | 18.0 |
| How long chlorhexidine gel was applied before cord detachment? | ||
| <7 d | 12 | 13.5 |
| 7–14 d | 54 | 60.7 |
| >14 d | 23 | 25.8 |
| Unwanted event experienced using chlorhexidine gel for cord care | ||
| - Delayed cord detachment | 68 | 76.4 |
| - Heals poorly | 20 | 22.5 |
| - Bleeding | 1 | 1.1 |
| Used chlorhexidine gel only while in the hospital? | ||
| - Yes | 25 | 28.1 |
| - No | 64 | 71.9 |
From Table 5, how soon after birth the chlorhexidine gel was applied for umbilical cord care (p=0.021) and how long the gel was applied for before detachment (p=0.047), were significant predictors of delayed cord detachment by postpartum women. Specifically, the odds of perceiving the delayed detachment were 2.2 times (95% CI 1.13 to 4.39) higher among women who applied it shortly after birth and 2.7 times (95% CI 1.01 to 7.41) higher among those who applied it for a larger number of days. The odds of perceiving delayed cord detachment was the same for both those who kept the cord dry and those who applied other agents (p=0.403).
Table 5.
Predicting delayed cord detachment among women that used chlorhexidine gel (n=89)
| 95% CI for OR | ||||
|---|---|---|---|---|
| OR | p | Lower | Upper | |
| How soon after birth was chlorhexidine gel used for umbilical cord care (In days, hours and minutes) | 2.227 | 0.021 | 1.131 | 4.388 |
| Whether cord was kept dry or other agents were applied | 0.521 | 0.403 | 0.113 | 2.400 |
| How long did you apply chlorhexidine gel before the cord detached: <7 days, 7–14 days and >14 days | 2.737 | 0.047 | 1.012 | 7.405 |
| Constant | 5.671 | 0.142 | ||
χ2=9.200; p=0.027.
The findings in this study, as presented in Table 6, also showed a significant association between the educational status of the women and their use of chlorhexidine gel (χ2=11.746, p=0.019) for umbilical cord care. Use was higher among those with tertiary education than among those possessing lower academic qualifications. As shown in Table 7, parity was not significantly associated with the use of chlorhexidine gel among participants (p=0.736).
Table 6.
Association between educational status and use of chlorhexidine gel among postpartum women at Poly General Hospital, Enugu
| Use of chlorhexidine gel | |||||
|---|---|---|---|---|---|
| Yes | No | Total | χ2 | p | |
| Educational | 11.746 | 0.019 | |||
| - Formal education | 10 (41.7) | 14 (58.3) | 24 | ||
| - Senior secondary school | 30 (37.0) | 51 (63.0) | 81 | ||
| - Diploma/NCE | 15 (53.6) | 13 (46.4) | 28 | ||
| - First degree | 25 (54.3) | 21 (45.7) | 46 | ||
| - Higher degree-MSC, PHD | 6 (100.0) | 0 (0.0) | 6 | ||
Table 7.
Association between parity and use of chlorhexidine gel among postpartum women at Poly General Hospital, Enugu
| Use of chlorhexidine gel | |||||
|---|---|---|---|---|---|
| Yes | No | Total | χ2 | p | |
| Parity | 1.997 | 0.736 | |||
| 1 | 8 (44.4) | 10 (55.6) | 18 | ||
| 2 | 19 (45.2) | 23 (54.8) | 42 | ||
| 3 | 30 (40.5) | 44 (59.5) | 74 | ||
| 4 | 17 (54.8) | 14 (45.2) | 31 | ||
| >4 | 10 (50.0) | 10 (50.0) | 20 | ||
Similarly, Table 8 showed a significant association between knowledge of chlorhexidine gel for umbilical cord care and its use, with a χ2 value of 61.843 and p<0.001. This implies that as knowledge of chlorhexidine gel for umbilical cord care increases, there is a greater likelihood that it will be used by postpartum women to provide umbilical cord care for their neonates.
Table 8.
Association between knowledge of chlorhexidine gel and its use among postpartum women at Poly General Hospital, Enugu
| Use of chlorhexidine gel | |||||
|---|---|---|---|---|---|
| Yes | No | Total | χ2 | p | |
| Knowledge of chlorhexidine gel | 61.843 | <0.001 | |||
| - Good | 69 (76.7) | 21 (23.3) | 90 | ||
| - Poor | 20 (19.8) | 81 (80.2) | 101 | ||
Discussion
Knowledge on the use of chlorhexidine gel in umbilical cord care among postpartum women
The findings of this study revealed that a little more than one-half of postpartum women attending the postnatal clinic at the study setting had poor knowledge about chlorhexidine use in cord care. This may be a result of a preponderance of inaccurate information on cord care from significant others, such as mother-in laws and other community members in the study setting. A majority had heard of chlorhexidine gel, of which their information source was chiefly through a health professional, and this emphasises the key and central role that healthcare providers play in providing evidence-based information. Similarly, in a recent study, Mohammed et al. revealed that 35.1% of participants had poor knowledge of standard cord care with respect to the use of chlorhexidine gel and methylated spirit, among others.26 On the other hand, the findings in this study are in disagreement with those of Afolaranmi et al., whose results revealed that the overall level of knowledge of cord care was adjudged as good among 239 (73.8%), with the other 85 (26.2%) having a poor level of knowledge.22 Although knowledge of chlorhexidine use for umbilical cord care in this study was poor, it was much better than that found by Onubogu et al.,14 where only 2.8% were aware of chlorhexidine gel. Differences in the findings could be a result of the variation in study settings, time and characteristics of the participants. This study also revealed no significant association between knowledge of chlorhexidine gel and educational status of the women (p=0.072). By contrast, Onubogu et al. found maternal education to be significantly associated with knowledge of chlorhexidine use in cord care.14
Use of chlorhexidine gel in umbilical cord care among postpartum women
Only 89 (46.9%) of participants had ever used chlorhexidine gel in umbilical cord care, while 25.7% (49) only used chlorhexidine for umbilical cord care in their last baby. Fewer postpartum women had ever used chlorhexidine gel for umbilical cord care in the present study compared with the findings of Aitafo et al., where the results revealed that 74 (58.7%) perceived it was effective, and used it.28 A 2022 study in Kenya revealed that only 1.3% used chlorhexidine gel for cord care, which is a much lower percentage compared with the current study.30 The findings of this study revealed that parity of the women was not significantly associated with utilisation of chlorhexidine gel (p=0.736). The utilisation was almost the same for different parities. This is similar to the work of Dhingra et al., where the results revealed that the level of utilisation has no association with the demographic characteristics of the participants (p<0.05).31
Predicting delayed cord detachment among women who used chlorhexidine gel
How soon after birth the chlorhexidine gel was applied for umbilical cord care (p=0.021) and how long the gel was applied for before umbilical cord detachment (p=0.047) were significant predictors of delayed cord detachment among the study population. This implies that postpartum women who applied the chlorhexidine gel shortly after birth (in less than 1 h) noticed delayed cord detachment and the women who applied chlorhexidine gel for a larger number of days also noticed delayed cord detachment. In 2019, Roba et al. noted, in their systematic review and meta-analysis concerning application of 4% chlorhexidine to the umbilical cord stump of newborn infants in lower income countries, that chlorhexidine gel use delays the cord separation time by about 2.5 d in the hospital setting and 2 d in the community.32 This finding may discourage mothers from using chlorhexidine gel, especially as evidence has shown that newborns benefit from early application, particularly within 24 h of birth.33,34 This reported delay in umbilical cord detachment could be one of the reasons why some mothers may prefer to use other materials for cord care, irrespective of the evidence-based benefits accruing from its use. In a similar study among healthcare providers, it was reported that with the application of chlorhexidine gel to the umbilical stump, the cord takes longer to heal because it leaves the cord wet, which delays the healing process, and that they prefer to use the spirit.30
In the present study, there was no significant relationship between delayed cord detachment as reported by respondents and whether the cord was left dry or other agents were applied (p=0.403), as shown in Table 5. Postpartum women who kept the cord dry after applying chlorhexidine gel and those who did not had the same experience. Although the WHO recommends dry cord care for best results,17 keeping the cord dry after chlorhexidine gel application did not significantly predict delayed cord detachment in the study population. Health workers in a related study reported that the application of chlorhexidine gel leaves the cord wet, which delays cord detachment and the healing process, and that they prefer to use methylated spirit. The study, however, highlighted that to overcome this barrier, community mobilisation and testimonials from mothers who reported fast cord healing and infection control should be implemented.30 This is because perception of increased separation time might negatively affect the likelihood of widespread acceptance of the intervention in subsequent scaling up activities.
Association between educational status and use of chlorhexidine gel among postpartum women at Poly General Hospital, Enugu
There was a significant association between educational status of the women and their use of chlorhexidine gel (p=0.019). The use was higher among those with tertiary education, especially those with a higher degree (use: formal [41.7%], secondary [37.0%], diploma/NCE [53.6%], first degree [54.3%] and higher degree [100.0%]). This study has shown that higher educational attainment is associated with a greater likelihood that the mother will use chorhexidine gel for caring for the neonate. This pattern can be attributed to the large health inequalities brought about by education.35
Association between knowledge of chlorhexidine gel and its use among postpartum women at Poly General Hospital, Enugu
There was a significant relationship between knowledge and the use of chlorhexidine gel among women at Poly General Hospital, Enugu (p<0.001). Women with good knowledge were associated more with the use of chlorhexidine gel than those with poor knowledge (use: good knowledge [76.7%] and poor knowledge [19.8%]); the likelihood increases approximately four times (RR=3.872; 95% CI 2.573 to 5.826) and the odds 13 times (OR=13.307; 95% CI 6.665 to 26.569). By implication, as more women become more knowledgeable about chlorhexidine use for umbilical cord care, its use is expected to increase. Health educational intervention for the purpose of increasing chlorhexidine use in umbilical care is recommended as a strategy to optimise use and decrease the negative consequences of poor umbilical cord care, such as sepsis. It has been affirmed in previous research that a supportive educative nursing intervention programme could effectively improve the knowledge of CHX gel for umbilical cord management among mothers.36
There are some limitations to the current study. First, because it was impossible to utilise a direct observational method to assess the use of chlorhexidine gel for umbilical cord care, these data were obtained by relying on mothers’ reporting, which can be at risk of bias. Second, recall of an umbilical care regimen can be affected by the passage of time, because this study was not restricted to mothers who are currently using chlorhexidine gel for umbilical cord care. Interpretation of these results should bring these limitations into consideration.
Conclusions
Knowledge of chlorhexidine gel use in umbilical cord care was found to be below average, as less than one-half of the postpartum women studied had good knowledge. Sustained caregiver education and creation of awareness may contribute to improving knowledge in this population. Although less than one-half of the study population used chlorhexidine for umbilical newborn cord care, the proportion of women who utilised chlorhexidine gel in this study has improved compared with some documented studies. Healthcare providers are encouraged to provide comprehensive education because, as more awareness is created regarding the use of chlorhexidine gel in cord care, it is expected that both its knowledge and use will improve over time. In addition to providing health education, nurse researchers should design research that can provide insights into how knowledge of chlorhexidine gel use for umbilical cord care translates to its use. Other factors associated with the use of chlorhexidine gel for umbilical cord care should also be explored.
Acknowledgements
None
Contributor Information
Chidinma E Israel, Department of Nursing Sciences, College of Medicine, University of Nigeria, Enugu Campus, Enugu 400106, Nigeria.
Kareen O Attama, Department of Nursing Sciences, College of Medicine, University of Nigeria, Enugu Campus, Enugu 400106, Nigeria.
Hope Chizolum Opara, Department of Nursing Sciences, College of Medicine, University of Nigeria, Enugu Campus, Enugu 400106, Nigeria.
Chikaodili N Ihudiebube-Splendor, Department of Nursing Sciences, College of Medicine, University of Nigeria, Enugu Campus, Enugu 400106, Nigeria; Department of Midwifery/Child Health Nursing, African Centre of Excellence for Public Health and Toxicological Research, University of Port Harcourt, Rivers State, 500004, Nigeria.
Ngozi J Omotola, Department of Nursing Sciences, College of Medicine, University of Nigeria, Enugu Campus, Enugu 400106, Nigeria.
Authors’ contributions
CEI, KOA and HCO designed and conceived the study, including the data collection and data analysis. CEI and CNI performed the data analysis and statistical analysis. CEI, CNI and NJO performed the literature search, manuscript preparation and editing. All authors reviewed and approved the final manuscript. CEI is the guarantor for this study.
Funding
None.
Competing interests
None declared.
Ethical approval
Ethical approval with certificate number MH/MSD/REC23/34 was obtained from the Ethics and Research Committee of Enugu State Ministry of Health.
Data availability
Due to privacy and ethical concerns, data for this study will be made available on request.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
Due to privacy and ethical concerns, data for this study will be made available on request.