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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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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
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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
fewer mothers having their first baby (primiparas) 38.5% compared to 61.5% mothers who
were having more than one baby (multiparas). Majority of the neonates were delivered in a
hospital setting 166 (99.40%) and only 1(0.60%) neonate was delivered at home. Majority of
the respondents 77(46.11%) were employed while 53(31.74%) were unemployed.
Table 1 below summarizes the socio-demographic characteristics of the study participants
Table 1: Maternal and neonatal Socio-demographic characteristics Maternal characteristics
Variable N Mean (SD)
Age 167 26.38 (5.42)
Sex N Proportion (%)
Female 158 94.61
Male/female (both parents) 9 5.39
Relationship with the neonate N Proportion (%)
Mother 163 97.60
Mother/ Father 4 2.40
Parity of the respondent N Proportion (%)
Para =1+0 64 38.50
Para = ≥2+0 102 61.50
Respondent’s Occupation N Proportion (%)
Business / self employed 22 13.17
Employed 77 46.11
Student 15 8.98
Unemployed 53 31.74
Respondent’s Religion N Proportion (%)
Protestants 94 56.3
Catholic 73 43.7
Neonatal characteristics
Age & gestation N Mean (SD)
Age 167 15 ±1.0
Gestation 167 38 ± 1.2
Other characteristics N Proportion (%)
Female 78 46.71
Male 89 53.29
Hospital delivery 166 99.40
Home delivery 1 0.60
Skilled attendance at birth 165 98.80
Unskilled attendance at birth 2 1.20
Sterile cutting instrument 164 98.20
Not sure of sterility 3 1.80
Hand washing before cord cutting 167 99.40
No hand washing before cord cutting 1 0.60
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Prevalence of adverse cord outcome such as delayed cord separation, umbilical
granuloma, and omphalitis
From our study prevalence of delayed cord separation, umbilical granuloma and omphalitis
was 17%, 14.7% and 29.5% respectively.
Table 2 below summarizes the prevalence of adverse cord outcome
Table 2: Prevalence of adverse cord outcomes
Variable N n (%)
Umbilical granuloma 163 24 (14.72)
Omphalitis 166 49 (29.52)
Delayed cord separation 164 28(17.07)
Adverse cord outcomes 159 90(56.60)
Bivariate associations between categorical independent variables and adverse cord
outcomes
From our study, Pearson’s chi-square test for the associations between various maternal and
neonatal characteristics and adverse cord outcomes showed that cord care using chlorhexidine
digluconate gel (p< 0.0001), having the neonate bathed (p=0.008), method of bathing (p=0.012)
and health education provider (p=0.046) were significantly associated with cord outcomes.
Parity however, was tending towards significance (p=0.089). There was no significant
association between other socio-demographic characteristics such as age, occupation, income
status, religion and neonatal sex to the adverse cord outcome.
Table 3 below summarizes maternal and neonatal categorical characteristics in relation to
adverse cord outcome
Table 3: Bivariate associations between categorical independent variables and adverse cord
outcomes
Variable Cases
n (%)
Controls
n (%)
Chi-square
value*
OR p-value
Age
<24 years 39(43.3) 31(40.3) 0.161 1.135 0.688
>25 years 51(56.7) 46(59.7)
Parity
Primigravida 40(44.4) 24(31.6) 2.879 1.733 0.089**
Multigravida 50(55.6) 52(68.4)
Occupation
Employed 53(58.9) 46(59.7) 0.012 1.036 0.911
Unemployed 37(41.1) 31(40.3)
Income status
No income 39(43.3) 31(40.3) 0.161 1.135 0.688
Has income 51(56.7) 46(59.7)
Religion
Catholic 44(48.9) 29(37.7) 2.126 1.583 0.144
Protestant 46(51.1) 48(62.3)
Cultural beliefs on cord
care 68(75.6) 64(83.1) 1.432 0.628 0.231
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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
None
At least one cultural belief 22(24.4) 13(16.9)
Neonatal sex
Female 42(46.7) 36(46.8) 0.000 0.997 0.991
Male 48(53.3) 41(53.2)
Usual cord care
Chlorhexidine digluconate 27(30) 65(84.4) 49.665 12.639 0.0001**
Others 63(70) 12(15.6)
Neonate Bathing since
birth
Yes
71(78.9) 70(93.3) 6.867 3.746 0.008**
No 19(21.1) 5(6.7)
Method of bathing
Immersion 50(70.4) 36(50) 6.220 0.420 0.0126**
Sponge 21(29.6) 36(50)
Health education provider
Health professional 64(72.7) 65(85.5) 4.398 0.450 0.046**
Other 24(27.3) 11(14.5)
*Asymptotic Pearson’s; **Significant at alpha = 0.1
Adverse cord outcome in relation to maternal and neonatal characteristics (measured
on a continuous scale)
From this study’s results of unpaired samples, pooled variance t-tests for the association
between maternal and neonatal characteristics (measured on a continuous scale) and adverse
cord outcomes showed no significant association between age of the respondent, age of the
neonate as well as gestation and adverse cord outcomes.
Table 4 below summarizes maternal and neonatal characteristics measured on a continuous
scale in relation to adverse cord outcome.
Table 4: Association between continuous independent variables and adverse cord outcomes
Variable Cases Controls
Mean±SD Mean± SD Diff. in means t- value* P value
Maternal age 26.22 ±5.10 26.69±6.05 0.473 0.534 0.5938
Age of neonate 15.22±1.07 15± 0.98 -0.222 1.336 0.1830
Gestation 38.81±1.33 38.84±1.06 0.029 0.150 0.8800
*Independent samples t-test assuming equal variance
Multivariable analysis
In this study, we estimated the binary logistic regression models for both unadjusted and
adjusted effects. We estimated all models on the additive scale and used Wald test to test
hypothesis of homogeneity of odds ratios. In unadjusted analysis, five variables were protective
of adverse cord outcomes namely: multiparity (OR=0.625), use of chlorhexidine digluconate gel
as a usual method of cord care (OR=0.05), sponge bathing (OR= 0.42), having no cultural belief
on cord care (OR=0.62) and health education by a health care professional (OR=0.43). On the
other hand, having at least one cultural belief about cord care, bathing by immersion and health
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education from other sources other than health professionals were risk factors for adverse cord
outcomes.
In adjusted analysis, our study results showed that primiparity (OR=1.66), use of other methods
for usual cord care (OR=11.81), bathing the baby by immersion (OR=1.57) remained key risk
factors for an adverse cord outcome. However, cultural beliefs on cord care and health
education provider were neither protective nor risk factors for adverse cord outcomes.
Table 5 below summarizes the results for unadjusted and adjusted analysis.
Table 5: Crude and adjusted regression coefficients, odds Ratios and 95% confidence intervals
for the association between maternal/neonatal characteristics and adverse cord outcomes
Variable Coefficient
(β1)
Crude
OR Coefficient
(β2)
Adjusted
OR
Confidence
Interval
P- value
Lower Upper
Multipara -0.47 0.625 -0.4063 0.666 0.283 1.570 0.353
Primipara 0.550 1.733 0.5104 1.666 0.7087 3.9164 0.2417
At least one
cultural belief
0.534 1.70 -0.068 0.935 0.294 2.970 0.909
No cultural belief -0.465 0.627 -0.0659 0.936 0.2958 2.9626 0.9106
Chlorhexidine
digluconate
-2.87 0.05 -2.659 0.070 0.026 0.188 0.000*
Other methods 2.536 12.638 2.469 11.813 0.625 30.171 0.000*
Bathing by
Immersion
0.838 2.31 0.453 1.573 0.671 3.686 0.297
Bathing by Sponge -0.867 0.420 -0.4810 0.618 0.265 1.439 0.264
Health provider as
educator
-0.899 0.430 0.013 1.013 0.308 3.327 0.983
Other source of
information
0.795 2.215 0.1223 1.130 0.348 3.667 0.8386
*Significant at alpha = 0.05
DISCUSSIONS
From our study findings, prevalence of adverse cord outcomes (umbilical granuloma, delayed
cord separation, omphalitis) in Nakuru County and Referral Hospital was high compared to
national and global prevalence. This could be as result of use of unsafe and contaminated water
for domestic purposes and when handling the cord which is prevalent in most parts of Nakuru
County. Also use of harmful and unsafe cord practices and failure of standardization in
implementing the W.H.O guidelines on cord care in Nakuru County Referral Hospital could have
contributed to the observed high prevalence of adverse cord outcomes. The findings of this
study were similar to a study by Kinanu and colleagues which found high prevalence of
omphalitis in Nakuru County Hospital [8].
Relationship between socio demographic characteristics and cord outcome
From our study, maternal and neonatal socio demographic characteristics such as age, sex of
the neonate, religion, occupation and income status were found not having a significant
association with adverse cord outcome despite existing literature showing significant
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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
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