Health experts urge use of medicine to prevent umbilical cord infections
By Delfhin Mugo
On a hot Wednesday afternoon in one of the many homesteads that make Kaya West Village in Bungoma County, a young mother sits on a wooden chair taking cover from the sweltering sun.
Under the shade provided by her mud house, she carefully balances a baby on her arms, shielding her bundle of joy from the sun.
Mary Stella Wanjala, 19, who has been married for a year now, wears a smile as she welcomes a group of visitors — two community health volunteers (CHV), Ms Gladys Wanyonyi and Ms Lydia Nangendo, popularly known here as madaktari wa Kijiji (village doctors), to her homestead. As part of their effort in supporting the local healthcare system, the team is here on a routine visit. They stop to check on the young mother and her baby’s progress.
Looking at the young woman, there is no doubt she is proud to be a mother, she is cheerful, positive and quick to smile. But behind the smile though, the team learns, is a troubled first-time mother. Mary Stella has just returned from a nearby health facility with bad news: Her two-week-old baby boy was diagnosed with umbilical cord infection at the health facility.
Handing over the baby to the CHVs, who take turns to inspect the baby, Mary Stella tells her visitors that two days ago, she noticed purse oozing from the baby’s navel area, which she carefully wiped out with a piece of cloth. A day later, the baby’s stump started to bleed. Frightened, she called her mother-in-law to have a look.
Her mother-in-law supposed the bleeding could have been due to too much crying from the baby, but nonetheless advised her to take the baby to the hospital immediately.
According to the medical report on her mother and child health handbook, the baby was found to have umbilical cord infection, which can lead to sepsis, an infection responsible for the deaths of 15 per cent of newborns in the world annually, according to the World Health Organization (WHO).
Sepsis is a systematic bacterial infection affecting a new born in the first 90 days of life. When it occurs within the first three days, it is referred to as early onset sepsis, which paediatricians say is a very serious infection. Late onset sepsis occurs between the third and ninetieth day of a baby’s life.
“Sepsis is a killer,” Dr Kimani Ngaruiya, a consultant paediatrician says.
“It is actually a leading cause of mortality of infants, what we call neonatal sepsis.”
According to the 2014 Kenya Demographic Health Survey, sepsis accounted for 15.8 per cent of the neonatal deaths recorded. Other causes of neonatal death were reported to be birth asphyxia and birth trauma (31.6 per cent) and prematurity (24.6 per cent).
But thanks to a new medicine, 7.1% Chlorhexidine, in simpler terms CHX, infection of the umbilical cord, which could easily lead to sepsis, need not happen.
The nearest and most common option to CHX has been use of swabs or cotton wool dipped in surgical spirit to clean and sterilise the umbilical cord after birth. Ideally, the painless procedure results in the cord falling off within the first two weeks.
However, due to home deliveries, illiteracy and myriad social-cultural factors, many mothers, especially in rural areas, use crude, ineffectual methods to heal the umbilical cord wound — some smear mud on the wound, others soot, saliva, herbs, and even lizard poop, all which can lead to infection.
Joan Wanjala, a 34-year-old mother of eight from Lunakwe village, Bungoma County, says she has been there, done that. Of her eight children, seven were delivered at home, and each time, the village traditional birth attendant (TBA) would mix soil with some water and then smear the mixture on the newborn’s umbilical cord. Ms Wanjala would repeat the procedure once a day after bathing the baby, sometimes replacing soil with soot.
When women give birth at home, they go without the right medical care, and mother and child are usually at increased risk of infection.
For instance, as a result of improper cord care, two of Ms Wanjala’s babies developed serious infections of the cord, and even though they healed, she says it took a long time to get rid of the infection.
“I didn’t know what I know now, those days, our knowledge was limited to what the traditional birth attendant knew,” she says, adding that she is lucky her other four children did not fall sick, even though it would take close to a month for the cord to dry up and fall off.
That was then. Women in this village do not give birth at home any more, neither do they use crude means to ‘treat’ their children. In fact, Ms Wanjala’s last born, now two years old, was born in a hospital. When she was leaving, the nurses gave her chlorhexidine and demonstrated her to use it — her baby’s umbilical cord dried up in seven days.
And hers is not the only positive story here. In another corner of the village a couple of households away, the team of CHVs, now joined by child welfare officers from Save the Children, a child welfare international NGO, meets Ms Claret Nanjala, a mother of seven-month-old baby girl. As they settle down, Mr Owen Onyango, a Save the Children, joking asks Ms Nanjala whether she had a hard time looking for lizard poop for her baby. She breaks into hearty laughter.
No, I did not use any of those things,” she says, laughing.
She went against her mother-in-law’s advice to use soil or soot.
“She had insisted that I use traditional means but I refused,” she says with a smile.
In 2013, WHO added chlorhexidine digluconate (CHX) specifically 7.1 per cent concentration, to its Model List of Essential Medicines for Children after three clinical trials performed in Nepal, Bangladesh, and Pakistan proved it effective for specific use for umbilical cord care. A year later, the global health body issued a new guideline on umbilical cord care, formally recommending the use of CHX on newborns.
Chlorhexidine, which comes in solution or gel form, is an effective antiseptic that provides bactericidal action for 24 hours after a two-minute application.
It is recommended particularly for low and middle-income countries, for use in hospital and home deliveries, the aim to reduce the number of newborns that are likely to die from infection of the cord.
The need for proper cord care cannot be overemphasised, Dr Kimani told DN2. He explains that the umbilical cord, soon after it has been cut, can become a highway for microbials to get into the system of the baby, the same way nutrients would go directly to the entire body of the baby before they are born.
“Mothers who have used CHX says their baby’s cord heals in a short time. The stump will actually fall within one week, it should not go beyond 10 days. And the infection risk is significantly reduced,” he says.
Kenya’s Ministry of Health ratified the use of CHX in April 2013, consequently including it in the Kenya Essential Medicine list (KEML) for neonates. It has also come up with guidelines for its use by the providers and mothers.
Even though this is a step in the right direction, health experts argue, more needs to be done to scale up its use especially in rural areas where mothers, for lack of knowledge and alternatives, use crude methods.
And CHX is just catching up in other parts of the world. In fact, a global scale-up tracker put together by a group of professionals and organisations in the field under the banner Chlorhexidine Working Group (CWG) shows that currently, there are only 25 countries (11 of them are in Africa, including Kenya) in the implementation phase across the world.
Meanwhile at home, different organisations have taken up effort to improve uptake. Save the Children, for instance, rolled out a CHX signature programme, supported by GlaxoSmithKline, to improve maternal and child health in Bungoma County in 2016 in what they describe as ‘a widely successful pilot project’, across 28 health facilities.
Speaking from his office in Bungoma town, Festo Chikani, Save the Children’s child survival advocacy coordinator told DN2 that the project was started at the backdrop of a 2013 UN Children's Fund (UNICEF) survey that showed a high rate of neonatal mortality in western Kenya especially in Bungoma and Busia counties. According to the charity’s medical logistics officer, Mr David Githinjim for the two years between 2016 and 2018 that the pilot project ran, over 35,000 babies benefited.
The organisation has since handed the project over to the county government but has remained to provide technical support, consequently expanding its wings to 15 other counties with the aim of changing perceptions, attitudes and to make the antiseptic acceptable to the communities and healthcare workers.
“We are not providing the antiseptic to health facilities at the moment,” says Mr Githinji.
He added that at least 31 counties are implementing CHX.
Despite the successes, challenges abound. In some health facilities such as Lunakwe Dispensary, Cheptais sub-county Hospital in Mount Elgon constituency and Chwele sub-county Hospital in Kabuchai sub-county that DN2 had an opportunity to visit in Bungoma, many had not had CHX in their stock for some time.
Additionally, interviews with mothers attending postnatal clinics in the health facilities whose aim was to find out how well they understood umbilical cord care cast a shadow of doubt on the level of awareness being created by healthcare providers as many lacked this crucial knowledge.
Dr Nicholas Barasa, the medical superintendent at Chwele Sub-county Hospital, who is also the head of all health-related activities in Kabuchai sub-county, in both public and private health facilities, admits that facilities in the sub-county are struggling to provide CHX to mothers after Save the Children stopped the supply at the end of the pilot project.
Even though he blames it on limited finances and delay by The National Hospital Insurance Fund in reimbursing facilities for providing free maternity services, the fact is that most facilities here do not have a specific budget line for this crucial medicine could also be a great contributor.
It is not only health facilities in the sub-county that do not have the antiseptic, even surrounding drug stores where mothers would otherwise purchase on their way home rarely stock the product, further compounding the problem for mothers.
Back to Mary Stella’s predicament, her case clearly illustrates what’s bound to happen when such gaps exist.
Medical records in her mother and child health handbook shows that on discharge from hospital upon delivery, the facility nurse-in-charge had prescribed CHX. Mary Stella says that the nurse went as far as informing her mother-in-law in person, to purchase the product at a chemist since the antiseptic was out of stock at the time.
She did not, partly due to lack of money and partly due to the fact that drug stores are located miles away from her village.
Upon intervention, the healthcare provider indicated in the Handbook that lack of hygiene at home was suspected to be the likely cause of infection.
So, will the government show commitment to ensuring all newborns have access to CHX an importance drug that, if used correctly, can prevent sepsis, a killer infection? Time will tell.