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European Journal of Applied Sciences – Vol. 10, No. 2

Publication Date: April 25, 2022

DOI:10.14738/aivp.102.11487. Kithaka, J. W., Macharia, S., & Ngugi, J. (2022). Relationship Between Umbilical Cord Practices And Neonatal Cord Outcomes Among

Neonates Attending Nakuru Level Five County And Referral Hospital, Nakuru, Kenya. European Journal of Applied Sciences, 10(2).

162-171.

Services for Science and Education – United Kingdom

Relationship Between Umbilical Cord Practices And Neonatal

Cord Outcomes Among Neonates Attending Nakuru Level Five

County And Referral Hospital, Nakuru, Kenya

Judy W. Kithaka

Department of Population, Reproductive Health &

Community Resource Management

Kenyatta University, Nairobi, Kenya

Stephen Macharia

Department of Human Anatomy, Kenyatta University, Nairobi, Kenya

John Ngugi

Department of Paediatrics, Kenyatta University, Nairobi, Kenya

ABSTRACT

Background: Globally neonatal mortality rate is 22 per 1000 live births, 98% of

these deaths are from developing countries and umbilical infections contribute

significantly to the etiology of these deaths. Methods: A hospital based unmatched

case control study design with study population comprising of neonates 14 days and

older. Cases were neonates with umbilical granuloma, delayed cord separation and

omphalitis. Controls were neonates without the aforementioned conditions.

Collection of data was done using interviewer administered questionnaire and

analyses done using SPSS Version 26. Probability outcomes relative to the

predictors were predicted using logistic regression. Results: Prevalence of adverse

cord outcomes was 56.60%. 14.72% umbilical granuloma, 17.07% delayed cord

separation and 29.52% omphalitis. Use of chlorhexidine digluconate for cord care

was statistically significant in protecting an adverse cord outcome (OR=0.070,

p=0.000) while use of other substances for cord care was statistically significant in

predisposing the newborn to an adverse cord outcome (OR=11.813, p=0.000).

Multiparity (OR=0.666, p=0.353) and sponge bathing the baby (OR=0.618, p=0.264)

were protective while primiparity (OR=1.666, p= 0.241) and bathing the baby by

immersion (OR=1.573, p=0.297) were risk factors. Conclusions: Prevalence of

adverse cord outcomes (umbilical granuloma, delayed cord separation, omphalitis)

was high compared to the global prevalence thus a major public health concern.

Adoption of WHO evidenced based chlorhexidine digluconate policy should be

encouraged as a universally accepted method of cord care. The practice of home

based post natal visits by community health workers should be strengthened as a

way to link facility recommendations to the home environment.

Keywords: Umbilical cord care, umbilical granuloma, delayed cord separation, omphalitis

INTRODUCTION

The developing fetus has a umbilical cord used for nourishing and excretory functions to the

fetus [1]. Following delivery of the baby, the cord is ligated and cut. The remaining cord serves

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Kithaka, J. W., Macharia, S., & Ngugi, J. (2022). Relationship Between Umbilical Cord Practices And Neonatal Cord Outcomes Among Neonates

Attending Nakuru Level Five County And Referral Hospital, Nakuru, Kenya. European Journal of Applied Sciences, 10(2). 162-171.

URL: http://dx.doi.org/10.14738/aivp.102.11487

as a potential route of entry for pathogens and thus should be properly cared [2]. Yearly,

neonatal mortality is estimated to be 3 million worldwide with NMR at 22 per 1000 live births.

Of these global neonatal deaths, 13% are estimated to be as a result of adverse cord outcome

such as omphalitis [3]. Nearly all the estimated neonatal deaths occur in low social-economic

countries [3]. Majority of these deaths (75%) are said to occur in the first week of life and cord

associated infections such as omphalitis are a major contributor in approximately a third of

these mortalities [4]. If this trend continues, around half of neonatal death is therefore

projected to increase from 45% in 2015 to 52% in 2030[5]. Further the global initiative of

sustainable development goals (SDG) 3.2 targets to end all preventable neonatal deaths with all

countries aiming to reduce neonatal mortality to at least as low as 12 per 1000 live births by

2030.

In Africa unsafe umbilical cord care practices such as harmful application of topical and cultural

substances among others may increase the risk of cord problems leading to increased neonatal

morbidity and mortality [4]. UNICEF, KHSSPI, WHO, World Bank and UNDESA population

(2015) study showed the neonatal mortality rate in Kenya between 2011 and 2015 on average

was 27% which was higher than the target set of 25% by mid-2015 and to further reduce the

rate to 15% by 2017, which was not achieved. This is indicative of a worsening situation as it

hinders the national vision for achieving universal health for all.

Umbilical cord care practices remains a highly controversial subject among health care

providers and care givers despite having the recommended guidelines on cord care by the WHO

as described in WHO 2014 guidelines [6]. Often the recommendations given by health care

providers to the infant care givers is based on custom or personal beliefs and not supported by

evidence [7]. Thus our study sought to understand the relationship between umbilical cord

practices and the neonatal cord outcomes with emphasis on the adverse cord outcomes of

umbilical granuloma, delayed cord separation and omphalitis.

METHODS

Setting: the study was conducted in Nakuru Level 5 County and Referral Hospital, Kenya. The

hospital had 12,232 deliveries between February 2019 and February 2020 with a total of 662

neonatal deaths in the same period. 22% (146) of the neonatal deaths were associated with

complications arising from the cord (Hospital statistics, March 2021).

Study design and participants: The study design was hospital based unmatched case control.

Random sampling technique was used in selection of the sample size. The sample size

comprised of 167 respondents (90 cases and 77 controls). The design was used to determine

the causal relationship between umbilical cord practices and umbilical cord outcomes among

the neonates studied. Cases were all neonates 14 days or older with an adverse cord outcome

(neonatal omphalitis, delayed cord separation and umbilical granuloma) while controls were

the same as for the cases except for the absence of adverse cord outcome instead had a good

cord outcome (well healed cord). Informed consent was obtained from the caregiver. All

neonates below 14 days were excluded in the study since outcome of interest may have not

occurred and also neonates with congenital anomalies of the cord such as persistent urachusor

vitellointestinal fistula were also exempted from the study since the abnormality may

complicate the study findings. Demographic information and other relevant history to the study

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European Journal of Applied Sciences (EJAS) Vol. 10, Issue 2, April-2022

Services for Science and Education – United Kingdom

was collected using a researcher administered structured questionnaire. The tool further

collected the information on cord care practices such as the type of substance applied on the

cord, the method of bathing the infant and the health education shared regarding the cord care.

Additionally, a physical exam was done on the neonate’s umbilical cord so as to elicit the

information on the status of the cord and to aid in making a diagnosis of either a good well

healed cord or a cord with an adverse cord outcome. The adverse cord outcome of interest in

this study was presence of umbilical granuloma, delayed cord separation and omphalitis.

Umbilical granuloma was defined as a moist, fleshy, friable and pink granulation tissue

(mushroom-like) at the center of the umbilicus with a diameter of 3-10mm commonly seen

after cord separation. Delayed cord separation was defined as the cord that has remained

attached to the umbilicus more than 14 days. Omphalitis was defined as presence of redness of

the umbilical cord with or without pus, swelling of the cord with a foul smell, pus discharge and

erythema of the abdominal skin surrounding the umbilicus.

Data analysis: data collected was analyzed using Statistical Package for Social Sciences (SPSS)

version 26. Both descriptive and inferential statistics were used for data analysis and

interpretation. Descriptive characteristics of the sampled cases and controls were analyzed via

means, standard deviation, proportions to describe the basic attribute of the respondents and

the occurrence of an adverse cord outcome. In Inferential statistics bivariate associations and

multivariable regression model was done. Estimation of unadjusted odds ratio was done using

contingency table methods where each predictor was cross-tabulated against the outcome.

Computations of adjusted odds ratios and their 95% confidence interval were done. Association

between each predictor variable and the outcome was tested by use of chi-square test. A P- value of 0.1 was considered significant. A binary logistic regression model was used to

determine the association between predictors and cord outcomes while adjusting for

confounders. To construct a logistic model, variables that were significant from the bivariate

analysis were selected for entry. When choosing the predictors (confounders), P value method

was used where predictors with P < 0.1 were included in the model. Variables were entered

using a forward stepwise approach. Hypothesis tests for regression coefficients were done

using the Wald test.

Ethical considerations: Ethical approval for the study was obtained from the Institute’s Ethics

and Review Committee and permission granted by both the hospital administration and

Nakuru County. Informed consent was obtained from the participants caretakers. Neonates

with adverse cord outcome were reviewed and treated by a clinician.

RESULTS

Socio-demographic characteristics of study participants

This study achieved a total of 167 participants against the computed sample size of 152. Ninety

(90) were cases and 77 were controls. The mean age of the mothers under study was 26 years

(N=167) with a standard deviation of 5.42 while that of the neonates was 15.13 days (N=167)

with a standard deviation of 1.038. The youngest mother was 16 years while the oldest was 43

years giving an age range of 27 years and the youngest neonate was 14 days while the oldest

was 20 days giving an age range of 6 days. Majority of the caretakers who accompanied the

neonates were female (94.61%) compared to both parents (5.39%) while majority of the

neonates under study were males 89(53.29%) compared to females 78(46.71%). There were