Cleansing the umbilical cord during birth could reduce infections and mortality in babies in resource-poor countries

February 07, 2012

Two Articles published Online First by The Lancet suggest that cleansing of the umbilical cord during and after birth could reduce sepsis and mortality in babies in resource-poor countries.

In the first study, Prof Zulfiqar A Bhutta (Division of Women and Child Health, The Aga Khan University, Karachi, Pakistan) and colleagues assessed the effect of umbilical cord cleansing with 4% chlorhexidine (CHX) solution, with or without handwashing with antiseptic soap, on the incidence of umbilical cord infection (omphalitis) and neonatal mortality in babies in rural parts of Sindh province, Pakistan.

Clusters were defined as the population covered by a functional traditional birth attendant (TBA), and were randomly allocated to one of four groups. Liveborn infants delivered by participating TBAs who received birth kits were eligible for enrolment in the study. One intervention comprised birth kits containing 4% CHX solution for application to the cord at birth by TBAs and once daily by family members for up to 14 days along with soap and educational messages promoting handwashing. One intervention was CHX solution only and another was handwashing only. Standard dry cord care was promoted in the control group.

A total of 187 clusters were randomly allocated to one of the four study groups, with 9741 newborn babies delivered by participating TBAs. The data showed that cord cleansing reduced the risk of infection in babies by 42% and mortality by 38%. Handwashing appeared to have no effect on infection or mortality risk.

The authors conclude: "These results of these trials done in community settings lend support to the policy of application of chlorhexidine on newborn umbilical cord for prevention of omphalitis and mortality."

In the second study, Professor Abdullah H Baqui and Dr Luke Mullany (Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA) and colleagues assessed the effectiveness of two cord-cleansing regimens with the promotion of dry cord care in the prevention of neonatal mortality in Sylhet, Bangladesh.

The study area was divided into 133 clusters, that were randomly assigned to one of the two chlorhexidine cleansing regimens (single cleansing as soon as possible after birth; daily cleansing for 7 days after birth) or promotion of dry cord care. All live births were eligible; those visited within 7 days by a local female village health worker trained to deliver the cord care intervention were enrolled.

Around 10,000 babies were allocated to each group. Neonatal mortality was lower in the single-cleansing group (22.5 per 1000 livebirths) than it was in the dry cord care group (28.3 per 1000 livebirths; translating to a 20% reduction of mortality in the single-cleansing group). Neonatal mortality in the multiple-cleansing group (26.6 per 1000 live births) was 6% lower than in the dry cord care group, but did not reach statistical significance, an observation that the authors attributed to chance.

Compared with the dry cord care group, the authors recorded a statistically significant reduction in the occurrence of severe cord infection (redness with pus) in the multiple cleansing group (risk per 1000 livebirths=4.2 vs 1.2; a reduction in risk of 65%) but not in the single-cleansing group (risk per 1000 livebirths=3.3; a risk reduction of 23% vs dry care that was not statistically significant).

The authors conclude along with a previous study done in Nepal and the one in Pakistan referred to above that: "These data...provide evidence that chlorhexidine cleansing reduces risk of neonatal mortality and omphalitis; further randomised trials in sub Saharan-African settings are needed."

In a linked Comment, Dr David Osrin and Dr Zelee Hill, UCL Institute for Global Health, London, UK, say: "On balance, we think that sufficient evidence has accrued to claim proof-of-principle that application of 4% chlorhexidine to the cord stump can prevent omphalitis and neonatal mortality in high-mortality settings."

They add that families, as well as birth attendants, should be considered in use of this intervention, since in many remote locations it is family members that are assisting during homebirths.
-end-
Prof Zulfiqar A Bhutta, Division of Women and Child Health, The Aga Khan University, Karachi, Pakistan. T) 92-300-8236813 E) zulfiqar.bhutta@aku.edu / dhunmai.cowasjee@aku.edu

Professor Abdullah H Baqui,Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA. T) 410-967-1656 E) abaqui@jhsph.edu

Dr Luke Mullany, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA. T) 410-967-1656 E) lmullany@jhsph.edu

Dr David Osrin, UCL Institute for Global Health, London, UK. T) 91-981-983-7260 E) d.osrin@ucl.ac.uk

Lancet

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