Cord Care Practices and Omphalitis among Neonates Aged 3 - 28 Days at Pumwani Maternity Hospital, Kenya ()
Received 23 October 2015; accepted 4 January 2016; published 7 January 2016
1. Introduction
Each year, approximately four million neonatal deaths occur globally and infections account for 36% of these deaths [1] . Cord care practices may directly contribute to infections in the new-born which account for a large proportion of the four million annual global neonatal deaths [2] -[6] . Cord infections are more prevalent in developing countries because of the high rates of unhygienic cord care practices [7] . Omphalitis is an infection of the umbilical cord stump, defined as either pus discharge with erythema of the abdominal skin or severe redness with or without pus [8] [9] .
Data on the incidence of omphalitis in low-income countries is generally scarce, the available data estimate the risk to range between 2 and 77 per 1000 live births in hospital settings, with fatality rates of between 1% and 15% depending on the definition of omphalitis used [10] . Community-based data show even higher infection rates: for example, 105 per 1000 live births in Nepal [6] , 217 per 1000 live births in Pakistan and about 197 per 1000 live births in India [10] . Remarkably, no data are currently available from most countries in Africa where most deliveries still occur at home and where neonatal mortality remains high [1] .
As cord infections should be preventable in most cases [11] , it is important to identify best cord care practices to reduce neonatal mortality and morbidity and offer an alternative to widespread potentially harmful traditional practices. Examples of such practices include use of traditional herbs mixed with cooking oil or water that has been used to wash an adult woman’s genitals or application of ash, breast milk, fluid from pumpkin flowers, powder ground from local trees, cow dung, ghee and saliva that may be applied to the cord area and which may be harmful [9] [12] .
Furthermore, many maternal and new-born deaths can be averted through changes in household level practices regarding delivery and new-born care [13] . A set of practices that reduces new-born morbidity and mortality has been identified as essential and these include clean cord care (cutting and tying of the umbilical cord with sterilized instrument and thread), thermal care (drying and wrapping the new-born immediately after delivery and delaying the new-born’s first bath for at least six hours or several days to reduce the risk of hypothermia), attendants’ hand-washing practices and initiating breastfeeding within the first hour of birth [6] [14] [15] .
In Kenya though there is no available information on the prevalence/incidence of omphalitis, it is presumed to be a problem. It is also reported that mothers in Nairobi had good knowledge on need for hygiene when cutting the cord, but had poor practices in other aspects of cord care, and were afraid of handling the cord [16] . Therefore, this study sought to determine the cord care practices associated with omphalitis among neonates aged 3 - 28 days at Pumwani Maternity Hospital.
2. Methodology
This was a cross sectional study carried out at the Pumwani Maternity Hospital, Nairobi, Kenya. Participants consisted of mothers presenting with neonates aged 3 to 28 days at the child welfare clinic of the hospital. The sample size of 178 was calculated by using single population proportion formula (n = Z2pq/d2). They were selected using systematic sampling method. A structured questionnaire was administered to collect information on cord care practices including instruments used to cut and tie the cord, initiation of breastfeeding, thermal care, any substance application on the cord, methods used to care for the cord, appropriate application of diaper, washing hands and etc. Moreover, omphalitis was defined as pus discharge, redness with or without pus and swelling of umbilical cord.
The data were coded and then entered into a Microsoft excel spread sheet and analysed using Statistical Pack- age for Scientific Solutions (SPSS) Version 20.0. Results were expressed as frequencies and proportions. Chi- square statistics was used to test for significance. Odds ratios with corresponding 95% confidence interval were also calculated for the variables. Binary logistic regression was used to assess the roles of the cord care practices on omphalitis. Level of significance was set at a p value of less than or equal to 0.05.
The study received ethical approval from Kenyatta National Hospital/University of Nairobi (KNH/UON), Ethics and Research Committee. Written informed consent was sought from all study participants before being interviewed.
3. Results
3.1. Background Attributes of the Participants
The background characteristic of study participants is shown in Table 1. More female neonates (53.4%) than males (46.6%) were participated in the study. The ages of the neonates ranged from 3 days to 28 days with mean age of 11.7 days. Three quarters of the neonates (75.3%) were aged between 3 to 14 days while the age category of 15 to 28 days was 25.7%. The prevalence of umbilical cord infection was found to be 37.6% with 95% confidence interval of 30.48% to 44.72%. Among those who had umbilical cord infection, 49.3% presented with redness, 13.4% presented with swelling and 37.3% presented with pus.
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Table 1. Background characteristics of the participants.
The table further shows that about half of the mothers (46.6%) were in the age category of 23 - 29 years and about a third (34.3%) were 16 - 22 years. The educational level of education for the mothers was as follows; 33.2% in primary, 52.8% in secondary and 14.0% in tertiary. Most of the mothers (94.4%) were Christians whereas the remaining 5.6% were Muslims. More than two thirds (71.9%) of the mothers were married.
3.2. Descriptive Analyses of Cord Care Practices among the Mothers
A large percentage (94.9%) of the mothers indicated that the umbilical cord was tied with a cord clamp while only 5.1% used thread. About two thirds (63.5%) of the mothers initiated breastfeeding after one hour of delivery. Most of the mothers (93.3%) reported that they stay with the baby in the same room (Table 2).
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Table 2. Mothers’ knowledge and practices on cord care.
Air drying was the main method (54.5%) used for caring the baby’s umbilical cord followed by spirit application at 24.7%, saliva at 10.7% and warm salty water at 10.1%. Ninety six (53.9%) of the mothers tied the diaper below umbilical cord while the remaining (46.1%) tied the diaper above the cord. Majority of the mothers (84.8%) bathed their babies every day and 67.5% added hand/body soap to the bath water. About half (51.7%) of the mothers were using running water to wash their hands while the remaining 48.3% were using basin (Table 2).
3.3. Cord Care Practices Associated with Omphalitis
In the bivariate analysis, initiation of breastfeeding after one hour, application of saliva on cord, substances (hand/body soap) added to the bath water and using basin to wash hands were factors associated with omphalitis. However, in the multivariate analysis, initiation of breastfeeding after one hour and application of saliva on the cord remained significantly and independently associated with omphalitis.
Babies who were initiated breastfeeding after one hour of delivery were about 2.5 times more likely to develop omphalitis than those who were initiated within the first one hour [AOR = 2.47; 95%CI = 1.15 - 5.30; P < 0.05]. Babies whose mothers applied saliva to their umbilical cord had significantly 6.5 times more likely to have omphalitis [AOR = 6.59; 95%CI = 2.02 - 21.46; P < 0.01] than babies whose mothers practiced air drying (Table 3).
4. Discussion
The umbilical stump represents a unique but universally acquired wound in which devitalized tissue provides a medium that could support bacterial growth. Thus, the immediate care of the umbilical cord requires strict aseptic techniques following healthy clamping and severance of the cord. If these basic conditions of the best cord care practices are overlooked, grievous infections may occur [4] that can lead to sepsis and death.
The study shows that initiation of breastfeeding was a predicting factor for umbilical cord infection. Babies who initiated breastfeeding after one hour of delivery were about 2.5 times more likely to develop cord infection than those who were initiated within one hour. This is in agreement with a study carried out by Mullany et al. [3] who reported breast-feeding within the first hour after birth was associated with lower risk of infection in multivariate analyses. There are several biological mechanisms thought to account for the relationship between breastfeeding initiation and cord infection. Breast milk contains secretory IgA, lysozymes, white blood cells, and lactoferrin. It has been shown to promote the growth of healthy Lactobacilli and reduce the growth of E. coli and other Gram-negative pathogenic bacteria [17] . Early initiation and exclusive breastfeeding is associated with significant reductions in diarrhea and acute respiratory infections in neonates while other observational studies have demonstrated impact on infection specific mortality rates during the neonatal period [18] -[20] . In addition, breastfeeding in the first hour of life is also recognized by the WHO as an important component of protection and should be implemented as routine hospital practice in all countries in order to reduce neonatal mortality [4] .
In the present study, babies whose mothers applied saliva to care the cord had significantly 6.5 times more likely to have omphalitis than babies whose mothers practiced air drying. This practice is often harmful, because the mother’s saliva is liable to being contaminated with micro-organism, thus increasing the risk of infection. Internationally, WHO has advocated since 1998 for the use of dry umbilical cord care (keeping the cord clean without application of anything and leaving it exposed to air or loosely covered by a clean cloth, in case it becomes soiled it is only cleaned with water). World Health Organization recommends topical antiseptics (e.g., chlorhexidine) in situations where hygienic conditions are poor and/or infection rates are high [4] .
5. Conclusion
In conclusion, the prevalence of omphalitis among neonates was high. The study shows that initiation of breast feeding after one hour and application of saliva on the cord are predicators of omphalitis. Programs promoting cord care among mothers should raise awareness by emphasizing immediate initiation of breast feeding after delivery and discouraging the application of potentially harmful substances (e.g. saliva) to the umbilical cord.
6. Limitations
The study relied only on physical examination to assess umbilical cord infection. It did not include swab sam-
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Table 3. Cord care practices associated with omphalitis.
Abbreviations: COR = Crude Odds Ratio, AOR = Adjusted Odds Ratio, CI = Confidence Interval, *P < 0.05, **P < 0.01.
ples for culture test that would have determined the specific bacteria. Another limitation was reliance on the par- ticipants’ response to the questionnaire. However, collecting data with trained interviewers and anonymity would facilitate participants in disclosing their information.
Acknowledgements
We wish to express our profound gratitude to the respondents involved in this study for their cooperation and time. We also acknowledge the health workers and management staff of the Pumwani Maternity Hospital for their assistance.
The funding is from the Linked-Strengthening Maternal, Newborn and Child Health (MNCH) Research Training in Kenya. The grant is linked to Partnership for Innovative Medical Education in Kenya (PRIME-K). The project was supported by Award Number 5R24TW008907 from the US National Institutes of Health. The content is solely the responsibility of the authors and does not necessarily represent the official views of the US National Institutes of Health
Competing Interests
The authors declare that they have no competing interests.
Appendix I: Questionnaire in English and Swahili
Serial Number (Nambari).………………………..
Date (Tarehe): ……………………………………
Demographic data of mothers (Takwimu za wakazi wa akina mama)
1. Age in years: ______
Umri (miaka) _________
2. Level of education: Primary 
, Secondary 
, College 
, None 
Masomo Yako: Msingi 
, upili 
, chuo 
, hakuna 
.
3. Religion: Christian 
, Muslim 
, Others (Specify)……………………………
Dini: Ukristo 
, uislam 
, zingine (eleza) …………………………………
4. Marital status: Married ![]()
Single ![]()
,
Hali ya ndoa: ndio ![]()
, sinlge ![]()
.
Baby’s information (Maelezo ya mtoto)
1. Sex Male ![]()
Female ![]()
.
Jinsia: mume ![]()
, mke ![]()
2. Age in days: ……………………….
Umri (siku) ……………………….
3. Birth weight: ………………………
Uzito wa kuzaliwa ………………….
4. Status of the umbilical cord infection (assessed by the researchers):
Present ![]()
Absent ![]()
5. Description of umbilical cord infection
Redness/erythema ![]()
Pus ![]()
Swelling and/or foul smell ![]()
Others (specify)…………..
Cord care practices (Mazoea huduma kamba)
1. What was used to tie your baby’s umbilical cord?
Cord clamp ![]()
, Thread ![]()
, Others (Specify)……………………………………..
Ni nini ilitumiwa kufunga kitovu cha mototo wako?
Chaka ya kitofu ![]()
, uzi ![]()
, zingine (eleza) ………………………………………….
2. What was used to cut your baby’s umbilical cord?
Scissors ![]()
, Razor blade ![]()
, Knife ![]()
, Others (Specify)……………………………………..
Ni nini ilitumiwia kukata kitovu cha mototo wako? Makasi ![]()
, wembe ![]()
,
kisu ![]()
, zingine (eleza) ……………………………………..
3. When did you initiate breastfeeding to your child? ………………………………………
Ulianzisha kunyonya motto wako baada ya mda gani? ……………………………………
4. Do you always stay with your baby in the same room?
Yes ![]()
, No ![]()
.
Unakaa na mtoto kwa chumba kimoja kila wakati?
Ndio ![]()
, la ![]()
.
5. What do you apply on your baby’s umbilical cord?
Air dry ![]()
, Spirit ![]()
, Chlohexidine ![]()
, Others (Specify) …………………………….
Unatunza aje kiziki cha kitovu cha motto wako?
Hakuna ![]()
, spirit ![]()
, zingine (eleza) …………………………………
6. What do you do to keep the baby warm? …………………………………………………..
Nini kufanya ili kuweka mtoto mtamu? ..............................................................
7. How often do you bath your child? ………………………………………………………..
Ni mara ngapi wewe umwagaji wa mtoto wako? ......................
8. Do you add any substances (hand/body soap or Dettol) to the baby’s bath water?
Yes ![]()
, No ![]()
.
Je, kuongeza vitu yoyote ( mkono / mwili sabuni au Dettol ) kwa umwagaji wa maji mtoto ?
Ndio ![]()
, la ![]()
.
9. How do you bath your baby?
Immersion in water ![]()
Pour water over the body ![]()
Others (Specify) …………………………
Jinsi gani unaweza umwagaji mtoto wako ?
Kuzamisha katika maji ![]()
Kuifuta kwa kitambaa mtoto ![]()
zingine (eleza) ………………………
10. How do you apply Diaper/Napkin on your baby?…………………………….( Explain-observe)
Unamfung aje Diaper/Kitambaa motto wako? ……………………………….(eleza).
11. How do you wash your hands?
Basin ![]()
Running water ![]()
Ni vipi unanawa mikono?
bonde la ![]()
maji ya bomba ![]()
Thank you
NOTES
![]()
*Corresponding author.