Objective: The objective was to study umbilical care practices and risks in Parakou (North Benin). Patients and method: It was a cross-sectional and descriptive study carried out within a community from June 1 to August 31, 2013. It focused on all the infants born at the maternity of Parakou Health Center and their mothers. Results: Two hundred and ten newborns were included i.e. 101 boys and 109 girls. In 80.9% of cases, inappropriate substances had been applied to umbilical cord. Umbilical cord care quality was adjudged as poor, acceptable and good in 58.6%, 31.9% and 9.5% of cases respectively. A bacterial umbilical infection had been noted in 59.5% of newborns. Only 4.8% had sterile umbilical wound. The commonest bacteria were: Staphylococcus aureus (58.1%), Staphylococcus saprophiticus (53.3%), Escherichia coli (44.8%) and Pseudomonas aeruginosa (14.3%). The factors associated with umbilical infection were: low educational status of mother (p = 0.026), low-income occupation of mother (p = 0.021), customary practices to accelerate umbilical cord fall off (p = 0.007), short time to cord falling off lower than 6 days (p = 0.015). Conclusion: Umbilical cord care involves high risk for bacterial infection in our context. Strong actions must be taken within the community in order to reduce that risk.
According to the World Health Organization (WHO) estimates, ten thousand newborns die every day, of which 99% in developing countries. Neonatal infections are the cause of 30% to 40% of those deaths [
Morbidity and mortality related to umbilical cord infections have become rare in developed countries but they are still significant in developing countries. A community-based study carried out in Pakistan in 2011 proved that 21.7% of the 6904 examined newborns had umbilical infection. During the same study, the incidence of umbilical infections was estimated at 271.4‰ of live births [
・ To identify the community-based practices of umbilical cord care among newborns.
・ To determine, according to well-defined criteria, the proportion of newborns who received adequate umbilical cord care.
・ To determine the proportion of newborns bearing bacteria at the umbilical cord and the nature of those bacteria.
・ To identify the factors associated with umbilical infection.
It was a cross-sectional and descriptive study with prospective data collection conducted over a three-month period ranging from June 1 to August 31, 2013. The study population consisted of infants born at the maternity of the District Health Center (DHC) of Parakou during the period and their mothers. This health center is a first- level structure that performs on average 150 deliveries per month.
Inclusion criteria: all infants born alive at the maternity of the District Health Center of Parakou.
Exclusion criteria: The study did not include all newborns in bad condition at birth and who were referred to the CHUD-Borgou neonatal care unit. Those whose parents did not live in the town of Parakou or those whose parents refused to participate in the study were not recruited.
Sampling: Sampling was done for convenience in relation to the material and financial constraints. Thus, taking into account the criteria of inclusion and exclusion, all newborns delivered in DHC Parakou during the period participated in the study.
Data collection procedure: Some measures were set up within the DHC maternity of Parakou for the identi- fication of newborn and mother’s residence. Those measures consisted of a notebook where midwives men- tioned date of delivery, name of mother, her full address (area, house, phone number) and any other information likely to help find her residence. Before discharge from maternity, we requested and obtained the consent of each parturient who would like to participate in the study. At birth, an umbilical bandage was performed in each newborn with clean cotton, alcohol and cord stump was wrapped into a compress, the whole protected by an elastic bandage.
After discharge from maternity, data were collected using a questionnaire we drafted and administered to mothers during a visit at home between the 48th and the 96th hour after delivery. That questionnaire specifies practices and umbilical cord care provided to newborn since his birth. Each newborn benefitted from complete clinical examination, careful examination of umbilical wound and bacterial sampling by swabbing. Each mother was given a kit of sterile material (cotton, compress) in order to continue umbilical cord care. After each sample, an adequate umbilical bandage was performed with sterile material. Phone call and home visit were systematically made one week later to inquire about newborn’s health condition and time to umbilical cord separation.
At CHUD-Borgou laboratory, samples were cultured in special media to identify bacteria likely to be encountered.
The dependent variables were quality of umbilical cord care provided to the newborn (excellent, good, acceptable or poor quality of care) and absence or presence of umbilical infection.
The independent variables were socio-demographic (newborn’s sex, age of mother, ethnicity, religion, occupation of mother, mother’s educational status, parents’ socioeconomic status). They are related to different umbilical cord care practices (newborn bathing technique before cord falls off, substances used for cord care, time to umbilical cord falling off, hand washing before care, materials used in umbilical care, person who influenced the choice of practices). The clinical (fever, condition of umbilical wound, time for discharge from maternity) and bacteriological (bacteria encountered in umbilical wound sample) variables were also studied.
ü Quality of care
Drawing on national documents of standards of care to newborns, the following classification was used as part of this study.
The quality of care was adjudged as excellent when:
・ newborn is wiped by means of a clean towel wet with warm water without wetting stump until umbilical cord falls off,
・ hands are washed with water and soap before umbilical care,
・ cotton wool and compress used are sterile,
・ disinfection is done with alcohol alone followed by application of 2% of aqueous eosin everyday till umbilical cord falls off,
・ umbilical cord is kept dry protected by a light bandage.
It is adjudged as good when:
・ newborn is wiped with a wet clean towel till umbilical cord falls off,
・ hands are washed with water and soap before umbilical care,
・ cotton wool and compress used are clean,
・ disinfection is done with 70˚ alcohol alone with or without application of 2% aqueous eosin,
・ umbilical cord is kept and protected by a light bandage.
It is adjudged as acceptable when:
・ newborn is given a bath with plenty of water before umbilical cord falls off,
・ hands are washed before care,
・ cotton wool and compress used are clean,
・ disinfection was done with antiseptics others than alcohol,
・ umbilical cord is kept dry with or without bandage.
Eventually, it was adjudged as poor for any other form of care.
ü Classification of parents socioeconomic status
We used INSAE (official statistics institute) rating criteria to assess socioeconomic status. It was determined by sum of values of the following items: housing, household materials, rolling stock and environmental hygiene. Each parameter will be given a value from 0 to 3; except environment which will be given a value from 0 to 1. A score < 4 will be considered as a low level, between 4 and 12 as an average level, and a score > 12 as a high level [
ü Umbilical infection or omphalitis and bacterial colonization
An umbilical infection or omphalitis was adopted as diagnosis if in addition to the presence of bacteria in the wound, there are redness and discharge of seropurulent fluid or if cord stump is putrid with or without fever.
Colonization is identified if in spite of presence of bacteria in the wound, newborn’s general condition is good without sign of apparent infection; umbilical wound does not give off a foul smell and does not discharge pus.
ü Selection of umbilical cord care method
As regards selection of umbilical cord care method, it is related to the person who influenced that choice. We considered three groups of persons, namely:
・ A health worker who may be a doctor, a nurse, a midwife, a nurse assistant who provided advice on umbilical cord care to mother or to her close relatives and friends after delivery or at any other moment.
・ Customary practices: this expression encompasses the advices given by a member of mother’s family or in-laws concerning umbilical cord care.
・ Neighbor or third party: when the advice was given by another person.
ü Notions of dry heat and moist heat in umbilical care
Regarding umbilical cord care after it falls off,
・ Dry heat refers to application to umbilical wound of an object which previously passed through a source of heat such as lantern, furnace, hot knife and hot stone.
・ Moist heat refers to application of hot water to umbilical wound.
The data collected were coded and entered with Epi info version 3.2. Once audited, those data were transferred to SPSS 19.0 statistical software for the design of crossed tables and statistical tests (Khi Deux, Student and Fisher Sinédécor). Excel software was used on a cross-cutting basis for the processing of some tables and construction of graphics. Significance level or threshold was defined by p < 0.05 and confidence 95% interval.
Approval was obtained from the ethics committee of the Faculty of Medicine of the University of Parakou and the administrative authorities at various levels for carrying out the current study. Parents of target newborns also gave their informed verbal consent. Confidentiality of data collected was guaranteed. During visits to the community, sick newborns identified were attended and provided care.
Of the 260 infants born at DHC/Parakou during the period, 210 were included in the study, 10 were referred to the CHUD-Borgou Neonatal Care Unit, 21 lived outside Parakou, the residences of 17 newborns were not found and 2 mothers had refused to participate in the study. Sex ratio was estimated at 0.92. Mothers’ mean age was 25.8 years ± 5.32 with extremes ranging from 15 to 45 years. As regards mothers’ educational status, 68 (32.4%) were not enrolled in school, 73 (34.8%) had primary school level and 69 (32.8%) had high school level and more. As far as mothers’ occupation is concerned, 81 (38.6%) were resellers, 50 (23.8%) were craft workers or caterers, 41 (19.5%) were housewives, 21 (10%) were high school or university students and 17 (8.1%) were civil servants. Concerning socioeconomic status, 101 (48.1%) of newborns were from families with low socioeconomic status. As far as religion is concerned, 127 (60.5%) of the mothers were Muslims, 77 (36.7%) were Christians and 6 (2.8%) were followers of endogenous religions.
The length of stay of newborns at the maternity of DHC/Parakou was less than six hours among 15 (7.1%), between six and twelve hours in 127 (60.5%) and higher than twelve hours in 68 (32.4%). Any of them has spent more than 24 hours at health center after birth.
Number | Percentage (%) | |
---|---|---|
Dendi and related ethnic groups | 45 | 21.4 |
Fon and related ethnic groups | 43 | 20.5 |
Bariba and related ethnic groups | 40 | 19 |
Yoruba and related ethnic groups | 33 | 15.7 |
Lokpa and related ethnic groups | 22 | 10.5 |
Ottamari and related ethnic groups | 13 | 6.2 |
Fulani and related ethnic groups | 9 | 4.3 |
Other ethnic groups* | 5 | 2.4 |
Total | 210 | 100.0 |
*The other ethnic groups were: Hausa 1, Igbo 2 and Sola 1.
ü Before umbilical cord falling off
Before umbilical cord falls off, 195 (92.9%) of newborns had been given bath with a lot of water. The others were cleaned with a wet towel until cord falls off. Seventy-three percent (153) of mothers claimed to have washed simply hands before providing umbilical cord care and 57 (27%) of them did not wash hands before care. After newborn’s toilet, 104 (49.5%) of the mothers cleaned umbilical cord with clean cotton. The other mothers used strips of fabric, cleaning or wiping rags, towels and cotton buds.
Herbs and by-products were used in a proportion of 13.8%. These were 2.8% of leaves of Synedrella nodiflora, leaves of Calotropis procera or Apple of Sodome (globular berry) in 1.4% of cases. Sap of Calotropis procera was used for 12 newborns (5.7%). As regards alcohol alone, it was used by 34 mothers (16.1%). The association of alcohol plus aqueous eosin was used by 6 mothers (2.8%). In 170 newborns (80.9%), inappropriate or harmful substances had been applied to umbilical cord. One substance was applied in 91 newborns (43.3%) and two substances simultaneously in 89 newborns (42.4%). For 23 newborns (10.9%), more than two substances were applied. No substance was applied to the umbilical cord of seven (07) newborns (3.3%). The frequency of substances application to umbilical cord stump was twice a day in 59% of cases, higher than two times a day in 26.2% of cases and once a day in 14.8% of cases. The mean time for umbilical cord falling off was 4.27 days ± 1.62 with extremes ranging from 2 to 9 days. For 177 (84.3%) of newborns, umbilical cord fell off before the 6th day of life, of which 5.7% before 72 hours of life.
ü After umbilical cord falling off
According to our criteria, 123 (58.6%) had received care of poor quality, 67 (31.9%) of acceptable quality and
Number** | Percentage (%) | |
---|---|---|
Alcohol | 81 | 38.6 |
Cooking salt | 57 | 27.1 |
Petroleum jelly | 50 | 23.8 |
Shea Butter | 41 | 19.5 |
Toothpaste | 35 | 16.6 |
Plant sap | 17 | 8.1 |
Maggi food cube | 12 | 5.7 |
Herbal mixtures | 12 | 5.7 |
2% aqueous eosin | 9 | 4.3 |
No application | 7 | 3.3 |
Other substances* | 26 | 12.4 |
*The other substances were: perfume = 6, talc = 5, ash = 4, palm kernel oil = 3, menthol-containing balm = 2, white chalk = 1, wasp nest clay = 1, ash + saliva + cauterization = 1, powder of basted shea nut = 1, penicillin ointment = 1, betadine = 1. **It is important to note that one newborn may benefit from the application of many substances at once during umbilical care.
Number | Percentage (%) | |
---|---|---|
Dry heat | 90 | 42.8 |
Moist heat | 66 | 31.4 |
Shea butter | 51 | 24.3 |
Antiseptics | 17 | 8.1 |
Others* | 13 | 6.2 |
*The other substances applied were: palm kernel oil 4, spices 2, talc 3, shea butter powder 1, petroleum jelly 1, nivaquineR + lyophilized injectable penicillin 1.
20 (9.5%) of good quality. No mother has applied care of excellent quality to her child. As regards choice of umbilical cord care practice, the mothers interviewed stated that they refer to custom in 143 (68.1%) of cases, to health workers’ advices in 39 (18.6%) of cases and to neighbors’ advices in 28 (13.3%) of cases.
After bacterial culture of umbilical wound samples, 14 types of bacteria were found out. Those bacteria were alone or in association.
In 72 newborns (34.3%), umbilical cord was very malodorous or fetid while in 131 of them (62.4%), there was fluid drainage in the umbilical wound, including 65% of seropurulent and 35% of serohematic fluid. Besides, among all the newborns examined during our home visit, 2 had fever and 3 had hypothermia. Taking into account clinical signs and bacteriological results, umbilical infection was diagnosed in 125 (59.5%) of newborns, bacterial colonization in 75 (35.7%) and 10 (4.8%) had sterile umbilical wound.
The factors associated with umbilical infection were: low pay occupation of mother (p = 0.021; RR = 2.39; CI: 1.26 - 4.52), customary practices for accelerating cord falling off (p = 0.007; RR = 2.15; CI: 1.43 - 3.22), short time to umbilical cord falling off lower than 6 days (p = 0.015; RR = 1.76; CI: 1.19 - 2.59), mother’s low educational status i.e. she is illiterate or has primary school level (p = 0.026; RR = 1.36; CI: 1.08 - 1.72). In contrast, using aqueous eosin has a protective effect for it does not facilitate the occurrence of umbilical infection with 0.034 p-value; RR = 0.29 and 0.10 - 0.85 CI.
The female predominance noted in the current study is similar to the one found out within Parakou district population during the General Population and Housing Census (RGPH 4) conducted in 2013 in Benin [
Number | Percentage (%) | |
---|---|---|
Staphylococcus aureus | 122 | 58.1 |
Staphylococcus saprophiticus | 112 | 53.3 |
Escherichia coli | 94 | 44.8 |
Pseudomonas aeruginosa | 30 | 14.3 |
Staphylococcus epidermidis | 20 | 9.5 |
Klebsiella pneumoniae | 19 | 9 |
Klebsiella azeniae | 14 | 6.7 |
Proteus mirabilis | 13 | 6.2 |
Proteus vulgaris | 5 | 2.4 |
Proteus Rettegeri | 4 | 1.9 |
Yeasts | 4 | 1.9 |
Klebsiella hymoleromotus | 2 | 1 |
Proteus morgani | 1 | 0.5 |
Streptococcus agalactiae | 1 | 0.5 |
25.80 ± 5.32 years. This relative young age of mothers was also reported by several Nigerian researchers. Abhulimhen-Iyoha et al. reported a mean age of 29.10 ± 4.91 years [
Several practices were identified in our study and they are involved in all levels of newborn care. As regards newborn toilet, it consisted of bath with a lot of water for the majority of newborns upon discharge from the maternity. This toilet method which is not in keeping with WHO 1999 recommendations [
As regards other substances applied to umbilical cord in our study, some of them would have chemical and medicinal properties, but the evidence of their antiseptic properties was not demonstrated scientifically. Those substances were used by mothers on the basis of real or reported experiences. The use of cooking salt and ash during newborn umbilical cord care would cause a faster umbilical cord falling off. Traditionally, ash is used for preparation of caustic soda. It is the corrosive effect of that ash that would facilitate quick falling off of umbilical cord. The antiseptic and refreshing properties of peppermint essential oil may explain the application of substances containing by-products of that plant such as toothpaste and “mentholatum” to umbilical cord. Besides, the moisturizing, soothing and healing properties of the butter and other cosmetics containing she butter may justify its use. The external use of Calotropis procera latex as antiseptic and healing substance was reported by Nacoulma et al. in 1996 during a study on medicinal plants and traditional medicinal practices in Burkina Faso [
After umbilical cord falling off, the dry or moist application of hot substances to umbilical wound predominated in our study. In fact, some mothers apply to umbilical wound strips of fabric lightly wet previously put in contact with a source of heat. Others apply directly to the base of umbilical cord a metal such as a knife raised to high temperature after being put in burning charcoal. This form of traditional cauterization is hazardous for newborn’s health. The use of heat sources to heal wounds is a current traditional practice in Benin. This may be due to heat property to eliminate germs. However, the temperature of water or tool applicable to skin must be low enough compared to the one required for eliminating a germ. That practice may be improved by using a clean fabric associated with simple hand washing with clean water and soap. But it entails a potentially high risk of burn for the newborn. That practice was also reported by Medewase et al. in a research work where 75.5% of the study populations apply that method like in our study [
It is obvious that newborn contamination risk is high if immediate environment of the latter is unhealthy. Quality of hand washing before umbilical cord care is a datum to be considered. In the current study, about three out of four mothers (73.3%) claimed to wash hands before umbilical cord care. However, six out of ten newborns had umbilical infection and only one out of twenty newborns of our series had sterile cord wound. Simple hand washing by using handcrafted traditional soft soap made liquid may reduce risk for umbilical cord infection in our context. A study on newborn home care practices carried out by Darmstadt et al. in 2007 [
Based on the findings of facts-focused research on umbilical care at birth, the American Academy of Pediatrics (AAP) recommended since 2010 up to now dry umbilical cord care after birth without systematic application of topical antiseptic agents [
As far as care quality is concerned, it was adjudged as good in only one out of ten newborns. No excellent practice of umbilical cord care for newborns was found out in the current study since guidelines related to newborn care were not complied with, even at the DHC maternity of Parakou. Moreover, newborns’ discharge from maternity was very early, sometimes before 6 hours of life while national standards require discharge from maternity after 72 hours of life [
As regards umbilical cord infection, it occurred in 3 out 5 newborns in the current study. Amorissani et al. found out a rate similar to ours i.e. a rate of 65.2% of the study population [
Concerning the bacteria which cause those umbilical infections, the predominance of positive-Gram bacteria identified was also reported by Mir et al. [
Several factors were associated with umbilical cord infection. Among them, the time of umbilical cord falling off had an influence on infection occurrence. This may be due to the application of aggressive and septic substances likely to separate umbilical cord within 48 hours. This ever quick falling off of umbilical cord exposes newborn to bleeding and infection risk. Besides, stoppage of care upon umbilical cord falling off reported by one out of 5 mothers further exposes that wound to infection risk. Umbilical infection is especially associated with substances applied to umbilical cord stump. Use of eosin appears as a protective factor against umbilical infection. There is no statistically significant relationship between use of a particular substance and occurrence of umbilical infection cord. The infection would be most associated with hygienic measures related to newborn care such as hand washing and preparation and storage conditions of the said substances. Opara et al. also concluded that the application of inappropriate substances is a risk for infection [
This study was conducted in the one of the twelve public and faith-based maternity of Parakou and having covered only three months of 2013, which did not allow drawing formal conclusions on the entire town. It is then necessary to carry out another large study that addresses the deficiencies listed above. However, the current study has demonstrated that approximately two out of three infants born at DHC/Parakou received umbilical care of poor quality. It also permitted to identify the substances and practices ordinarily used for that purpose within families. Eventually, this research work addresses the infection risk incurred by newborns and bacteria identified in umbilical wounds. Moreover, this research work points out the lack of training of health workers and of information available to mothers in the field of appropriate umbilical care practice.
No conflict of interest.
JosephAgossou,Julien DidierAdédémy,AlphonseNoudamadjo,Doué Yasmine GounouN’gobi,MarcellineHounnou-d’Almeïda,BlaiseAyivi, (2016) Newborn Umbilical Cord Care in Parakou in 2013: Practices and Risks. Open Journal of Pediatrics,06,124-135. doi: 10.4236/ojped.2016.61019