Research Article ISSN 2639-9458

Microbiology & Infectious Diseases

Umbilical Cord Care Attitude among the Caregivers and the Rate of
Development of Omphalitis
Abdullahel Amaan MBBS, FCPS (Pediatrics), MD1*, Sanjoy Kumer Dey MBBS, FCPS (Pediatrics), MD2, Khainoor
Zahan MBBS, MPH3, Mohtarama Mostari MBBS, MCPS, MD1, Azmery Saima MBBS, MD1,
Dr. Arif Hossain MBBS, MD4, Dr. Tahsinul Amin MBBS, MD5 and Mujibur Rahman Talukder MBBS, MD6
Resident (Neonatology), Bangabandhu Sheikh Mujib Medical
1

University (BSMMU), Dhaka.

Chairman, Department of Neonatology, Bangabandhu Sheikh

2

Mujib Medical University (BSMMU), Dhaka.

*
Correspondence:
3
Deputy Director, Bangladesh National Nutritional Council Dr. Abdullahel Amaan, MBBS, FCPS (Paediatrics), MD
(BNNC), Mohakhali, Dhaka. (Neonatology) Department of Neonatology, Bangabandhu
Sheikh Mujib Medical University (BSMMU), Dhaka.
Medical Officer (Neonatology), Bangabandhu Sheikh Mujib Medical
4

University, Dhaka. Received: 09 Jun 2022; Accepted: 15 Jul 2022; Published: 20 Jul 2022

Associate Professor, Department of Neonatology, Dhaka Medical

5

College Hospital, Dhaka.

Professor, Department of Paediatrics, Sher-E-Bangla Medical

6

College & Hospital (SBMCH), Barisal.

Citation: Amaan A, Kumer Dey S, Zahan K, et al. Umbilical Cord Care Attitude among the Caregivers and the Rate of Development
of Omphalitis. Microbiol Infect Dis. 2022; 6(4): 1-5.

ABSTRACT
Background: Of the annual 2.5 million global neonatal deaths, most occurring in developing countries, and one-third to one half
are attributed to infections. In low-income countries like Bangladesh, where home delivery is common and attendance by skilled
personnel is low, many babies are born in unhygienic conditions and infections of the umbilical cord stump are common. Exposure
of the freshly cut umbilical cord stump to pathogens may lead to local cord infections (omphalitis) that may progress to systemic
infection and death.

Objective: To evaluate the pattern of umbilical cord care practices and the rate of developmentof omphalitis.

Methodology: It was a prospective observational study included 80 neonates. This study was conducted over a period of six months
from May to November 2013 in the obstetrics unit of department of obstetrics and gynaecology, Sher-E-Bangla Medical College
Hospital, Barisal.

Results: A total 80 out born neonates, accompanying their mothers who were admitted due to their post-partum complications from
home delivery, were included in this study. Among them twelve (15%) were found to have omphalitis, of which nine (11.25%) were
with mild omphalitis and three (3.75%) with moderate omphalitis. Umbilical cords were mostly (58.75%) cut by used shaving blades
and tied by washed thread from home (88.75%). Most of the caregivers (65%) had educational qualification below primary level.
Forty-two (52.5%) of the eighty caregivers had not heard about WHO recommended dry cord care method. All of the caregivers applied
traditional substances to the cord and mustard oil was the commonest (75%) practice. It was applicable in all omphalitis cases. Statistically
significant relationship (p < 0.05) was found with omphalitis and cord cutting instrument, topical application of traditional substances to
the cord, caregivers’ educational status and knowledge about dry cord care.

Conclusion: Omphalitis rate among enrolled newborn was 15% cutting cord with unsterile instruments, applying traditional
substances to the cord and low educational status among the care givers are related with development of omphalitis.

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Keywords (WHO) has advocated for the use of dry umbilical cord care
Omphalitis, Umbilical cord care, Dry cord care. (keeping the cord clean without application of anything and
leaving it exposed to air or loosely covered by a clean cloth & in
Introduction case it becomes soiled, it is only cleaned with water). To reduce
Globally, 2.5 million children died in the neonatal period, at an the risk of sepsis in places where home deliveries are common,
average of 18 deaths per 1,000 live births in 2018. A majority neonatal mortality rate exceeds 30 per 1000 live births and there
of this mortality were accounted from low- and middle-income is practice of applying potentially harmful substances to the
countries (LMIC) [1]. Neonatal sepsis affects 6 to 21 babies per freshly cut cord, the WHO recommendation is applying 7.1%
1000 livebirths and is identified as one of major causes of newborn chlorhexidine digluconate solution at birth or gel delivering 4%
morbidity and mortality [2]. In the developing world sepsis chlorhexidine daily to the cord stump during the first week of life.
accounts for 26% of all neonatal death [2-6]. The application of chlorhexidine to the cord as an alternative to the
standard recommendation for dry cord care is particularly relevant
38% of deliveries in Bangladesh still take place in the home and where harmful substances are traditionally placed on the cord, and
in only 42% of cases, a skilled birth attendant is present [7]. In it can serve as a safe substitute [5,12,13]. Several successful trials
primary care settings, poor cord hygiene due to improper handling in South Asia supported this practice.
of the infant’s cord is a major contributor to the occurrence of
neonatal sepsis [8]. The objective of this study was to determine the prevailing patterns
of umbilical cord care practices among the mothers/caregivers of
Umbilical cord is one of the main portals of entry for microorganisms the newborns among the home delivery cases and to estimate the
that can cause newborn sepsis. This could be attributable to the rate of development of omphalitis among them.
prevailing sub-optimal hygienic conditions in the environment of
the baby that could result in a localized umbilical cord infection Methodology
(omphalitis), with potential spread of the microorganisms into the This observational study was performed during the period from
bloodstream via the patent umbilical vessels resulting in septicemia May to November 2013 in Obstetrics unit of department of
or infection of other organs. Optimal umbilical cord care practices obstetrics and gynecology, Sher-E-Bangla Medical College
during the first week of life have significant potential to reduce Hospital (SBMCH), Barisal. Some mothers in the ward were
neonatal death secondary to sepsis [8-10]. admitted due to their post-partum complications because of home
delivery. The newborns who were accompanying these mothers
A hygienic umbilical cord refers to a dry umbilical stump without were enrolled and observed in this study. Among them, those
signs of redness, warmth, swelling, pain, foul smell or pus [8]. who already had clinical features of sepsis & those who were
Contamination of umbilical cord can lead to local infections subsequently got admitted in neonatal unit were excluded. Prior
characterized by pus, erythema, swelling or systemic infections permission was obtained from the ethical review committee of
(e.g. sepsis), and is often caused by unclean cord cutting instrument SBMCH and informed written consent was taken from each of the
or through subsequent cord care practices. Such cord infections are participant caregivers.
associated with an increased risk of sepsis and neonatal mortality
[11,12]. Omphalitis was defined as an umbilical infection, which occurs
due to lack of cleanliness at the time of division of umbilical
The term clean cord care can be defined as [10] cutting the cord cord, and lack of care of the umbilical stump. Its seriousness
with a new or sterilized instrument (or a clean delivery kit) as well lies in the possibility of extension of this infection to portal vein,
as appropriate cord care, is a standard measure of newborn care liver, peritoneum, or hematogenous spread. It was graded into 3
[10,11]. categories: mild omphalitis (redness, swelling or pus restricted to
the cord stump), moderate omphalitis (redness, swelling or pus
Umbilical infection (omphalitis) is common among newborns in extending to the skin at the base of the cord stump less than 2 cm),
developing countries and may predispose to life-threatening neonatal severe omphalitis (inflammation extending >2 cm from the cord
sepsis. Incidence rates in newborns in nurseries from developing stump, with or without pus) [14].
countries range from 2 per 1000 to 54 per 1000, with figures from
Turkey as high as 77 per 1000 live birth. Case fatality rates range A semi-structured questionnaire was used to collect data from the
from 0-15% in this hospitalized [11]. Around the world, substances caregivers and thorough clinically examining the newborns.
are placed on the cord stump to promote healing. These substances
have included powders, food, oils, herbs or spices, hot compresses, Data were analyzed by using SPSS version 17. The qualitative data
charcoal, antiseptics, tar, machine or motor oil, breastmilk, petroleum were analyzed with chi-square (χ2) test. The level of significance, P
jelly, animal dung, among others. These practices are potentially = <0.05, was considered statistically significant.
harmful for the newborns, causing infection, especially sepsis [9].
Results
Internationally, since 1998, the World Health Organization Systematic random sampling enrolled 103 neonates. Every 3rd

Microbiol Infect Dis, 2022 Volume 6 | Issue 4 | 2 of 5

newborn was enrolled. Of them 23 were subsequently found
already having clinical features of perinatal complications (sepsis,
perinatal asphyxia). They were subsequently got admitted in Grades of omphali�s (n=12, 15%)
neonatal unit and were excluded from the study. Finally, eighty moderate,n=3,
04%
neonates (77%) were enrolled in the study, who accompanied their mild, n=09, 11%

mothers who were admitted in the obstetrics unit due to their post-
partum complications from home delivery. Most of them were
female, age < 3days, term, hailing from rural areas, from a low
socioeconomic background, from multiparous mothers and were Healthy n=68,
delivered by nonskilled birth attendants (Table 1). 85%

Table 1: Distribution of background characteristics among children born

at home (n=80).
Variables Frequency Percentage Figure 1: Grades of Omphalitis.
Gender
Male 37 46.25%
Female 43 53.75%
Among the newborns 71 (88.75%) were found to be tied by thread
Age of the newborn from home and remaining 09(11.25%) were with new sterile cord
Less than 3 days 64 80% clamp from market. Statistically there is no significant relationship
More than 3 days 16 20% between instruments used in tying the cord and omphalitis, where
2
Gestational age
χ = 1.790, p = 0.181 (Table 3).
Pre term 23 28.75%
Term 57 71.25%
Residence Table 3: Instruments used in tying umbilical cord and omphalitis (n=80).
Urban 09 11.25% Instruments used Frequency Percent p value
Rural 71 88.75% Thread from home 71 88.75 0.181
Monthly income New sterile cord clamp 09 11.25
Below 10,000/month 74 92.5%
Total 80 100.0
Above 10,000/month 06 7.5%
Educational status
Below primary 52 65% Among 80 neonates, 47 (58.75%) were found having their cord cut
Above primary 28 35% with used blade from home, among which 12 (25.53%) developed
Maternal occupation omphalitis. Omphalitis was significantly more among those in
Housewife 80 100%
whom a used blade was used in cutting the cord (p= 0.002) (Table 4).
Service holder 00 00
Maternal age
Below 18 09 13.75% Table 4: Instruments Used in Cutting Umbilical Cord and Omphalitis (N-80).
18-40 69 86.25% Instruments used Healthy Omphalitis χ2 Value p value
>40y 00 00
Used blade from home (n=47,
Parity 35 12 9.912 0.002
58.75%)
Primi 33 41.25%
Multy 47 58.75% New shaving blade from
33 00
Antenatal Care market (n=33, 41.25%)
Less than 4 visits 57 71.25% Total 68 12
4 or more visits 23 28.75%
Skilled attendant at birth
All of the caregivers applied traditional substances to the cord
No 67 83.75%
Yes 13 16.25% and mustard oil was the commonest (75%) practice. Out of 80
neonates, 60 (75%) were found to had mustard oil applied to
A total 80 out born neonates were included in this study. Among the umbilical cord and boric powder in 20 (25%). 25% of the
them twelve (15%) were found to have omphalitis (Table 2), of newborns, in whom mustard oil was used, developed omphalitis.
which nine (11.25%) were with mild omphalitis and three (3.75%) There was a statistically significant association between omphalitis
with moderate omphalitis (Figure 1). and application of mustard oil to the umbilical cord (n=60, 75%),
χ2 = 4.706, p=0.03 (Table 5).
Table 2: The Rate of Development of Omphalitis (n=80).
Condition of Umbilical Table 5: Application of substances to umbilical cord and omphalitis.
Number of Neonates Percentage (%)
Cord (n=80).
Healthy 68 85 Pattern of hand washing Healthy Omphalitis χ2 Value p value
Omphalitis 12 15 Mustard oil (n=60) 48 12 4.706 0.03
Total 80 100 Boric powder (n=20) 20 00
Total 68 12

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The hand-washing attitude before handling the neonates by the In case of tying the cords, 71 (88.75%) were found having their
caregivers was not satisfactory. Only 62.5% caregivers were cord tied with thread from home and remaining 09 (11.25%) were
found to ensuring hand hygiene before handling their newborn. It with new sterile cord clamp from market. Omphalitis was found
was not significantly associated for omphalitis, where χ2 =1.150, in 12 of those in whom cord was tied with thread from home.
p=0.284 (Table 6). Statistically there is no significant difference between instruments
used in tying the cord and omphalitis, where p=0.181. The entire
Table 6: Frequency of Ensuring Hand Hygiene Before Handling the respondent informed that, they washed the thread in hot water
Neonates and Omphalitis (N=80). before tying the cord, which is in favor of clean cord care practice.
Pattern of hand washing Healthy Omphalitis χ2 Value p value
Occasional (n=23) 18 05 1.150 0.284 Instruments used in cutting the umbilical cord have been found
Don’t wash (n=57) 50 07 to have significant effect on the incidence of omphalitis. None in
Total 68 12 this study was found to use sterile surgical blade. Among them,
47 (58.75%) were found to have their cord cut by previously used
The development of omphalitis was significantly low in those shaving blade from home, of whom 12 developed omphalitis. The
having educated caregivers. Most of the caregivers (65%) had remaining 33 (41.25%) used new shaving blade of which none
educational qualification below primary level. 91.6% of those who were affected (Table 3). Statistically significant difference has
developed omphalitis had their caregivers educational qualification been found in incidence of omphalitis between babies’ umbilical
below primary level. Educational qualification of mother was cord cut with new or used blades, where p=0.002. This finding
found statistically significant (Table 7). is consistent with other studies from south Asian and African
countries where in nonsterile instruments are commonly used to
Table 7: Educational Status of the Care Givers and Omphalitis. cut the cord [19,21,22].
Educational status of
caregivers
Healthy Omphalitis χ2 Value p value None of the neonates was found to be reared with dry cord care. In
Below primary (n=52) 41 11 4.413 0.036 all case, caregivers applied some traditional materials to umbilical
Primary and above (n=28) 27 01 cord, among which 60 (75%) were found to apply mustard oil and
Total 68 12 another 20 (25%) boric powder. Such attitude of applying some
substances, like mustard oil, spirit, saliva, ash, brick ash etc. has
Forty two (52.5%) of the eighty caregivers did not hear regarding also been found in studies in Nepal, Kenya and Nigeria, Zambia,
WHO recommended dry cord care. Those who developed omphalitis Ethiopia, Ghana [8,16,19,21-24]. Mustard oil was applied in all
have their caregivers ignorant about WHO recommended dry cord cases of omphalitis (Table 4). Statistically significant increase in
care (p= 0.000; χ2 =12.773) (Table 8). incidence of omphalitis has been found with application of mustard
oil (n=60, 75%) to the umbilical cord, p=0.03.
Table 8: Relation in Between the Knowledge of Dry Cord Care and Omphalitis.
Having knowledge Out of eighty care givers, only 23 (28.75%) have been found to
Healthy Omphalitis χ2 Value p value wash their hands occasionally before handling the neonates out
regarding dry cord care
Don’t know (n=42) 30 12 12.773 0.000 of which five have developed omphalitis and the remaining 57
Have heard about it (n=38) 38 00 (71.25%) don’t care about that, out of which seven have developed
Total 68 12 omphalitis (Table 5). It was not statistically significant for causing
omphalitis (p=0.284) as it was also found in a community- based,
Discussion cluster-randomized trial in Pakistan, where only in 2.14% cases,
Eighty healthy newborns were studied, who accompanied their handwashing was practiced before handling the neonates and
mothers admitted due to post-partum complications from home omphalitis developed in 5.26% cases who dont follow the hand
delivery, in the obstetrics unit of department of obstetrics and washing practice [12]. In a study in Kenya, 27.9% caregivers were
found to wash hands before taking care of the newborn [8].
gynecology in Sher-E-Bangla Medical College and Hospital,
Barisal from May to November 2013. Among them majority were
In case of educational status among the caregivers, 52 (65%) were
female (53%), term born (71%), age less than 3 days (80%), from
under primary level and the remaining 28 (35%) had an education
rural areas (88%), from multiparous mothers (58%) & delivered
above the primary level. Among the 12 omphalitis cases, 11 cases
by a traditional birth attendant (84%). were found with caregivers having educational level below primary
and 01 was with level above primary (Table 6). The influence
Among the study newborns, 12 (15%) cases were found to have of educational status of the caregivers on omphalitis was found
omphalitis. This is consistent with the community based studies statistically significant, p=0.036. Which was similar to the findings
in Pakistan, Zambia and Tanzania, where 21.7%, 11.5 and 12% in a community-based, cluster-randomized trial in Nepal where it
newborns diagnosed with omphalitis [12,14,15]. Among the cases was found that infants born to mothers in the highest educational
of omphalitis, 75% were found mild variety, which is consistence category had slightly less risk in development of omphalitis [16].
with the study result from Zambia (79.4%), and Nigeria (76.9%) Forty two (52.5%) of the eighty caregivers had not heard
[16,18]. about WHO recommended dry cord care method. Those who

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developed omphalitis have their caregivers ignorant about chlorhexidine cord cleansing on mortality, omphalitis and
WHO recommended dry cord care method & it was statistically cord separation time among facility-born babies in Nepal and
significant, p= 0.000 (Table 7). Bangladesh. Pediatr Infect Dis J. 2017; 36: 1011-1013.
11. Sitrin D, Perin J, Vaz LM, et al. Evidence from household
Statistically significant relationship (p < 0.05) was found with surveys for measuring coverage of newborn care practices. J
omphalitis and cord cutting instrument, topical application of Glob Health. 2017; 7: 020503.
traditional substances to the cord, care givers’ educational status 12. Mir F, Tikmani SS, Shakoor S, et al. Incidence and etiology
and knowledge about dry cord care. of omphalitis in Pakistan: a community-based cohort study. J
Infect Dev Ctries. 2011; 5: 828-833.
Limitations
13. WHO. WHO Recommendation on Newborn Health:
No microbiological evaluation was done for the omphalitis cases
Guidelines Approved by the WHO Guidelines Review
in the study. Binary logistic regression analysis of the predictors
Committee. Geneva: WHO. 2017.
for the outcome as omphalitis was also not done.
14. El Arifeen S, Mullany LC, Shah R, et al. The effect of cord
cleansing with chlorhexidine on neonatal mortality in rural
Conclusion
Bangladesh: a community-based, cluster-randomised trial.
Omphalitis rate among enrolled newborn was 15%. Cutting cord
Lancet. 2012; 379: 1022-1028.
with unsterile instruments, applying traditional substances to the
cord and low educational status among the care givers were related 15. Mullany LC, Darmstadt GL, Katz J, et al. Risk factors for
with development of omphalitis. umbilical cord infection among newborns of southern Nepal.
Am J Epidemiol. 2007; 165: 203-211.
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