Chlorhexidine cord care saved thousands of newborn lives in Nepal
Author: Leela Khanal, JSI Nepal (Accelerating SL@B advisory board member)
Sepsis in the first week or two of life is a major cause of newborn deaths. Deeply rooted cultural practices surrounding the care of the newborn’s umbilicus are a large part of the reason why Nepal’s neonatal mortality rate did not improve between 2006 and 2011 and remained stagnant at 33 deaths/1000 (DHS survey of Nepal 2006 and 2011) live births. Mothers and grandmothers preferred traditional practices that contributed to the high neonatal death rate, such as treating the fresh umbilical stump with turmeric, mustard oil paste, ash, unknown medicine, even cow dung or vermillion—the bright red cosmetic powder used by Hindu women. These practices can lead to the introduction of pathogens, sepsis and neonatal deaths.
Nepal is rapidly increasing the rate of facility delivery, but we also know that mothers and babies are almost immediately discharged into the same environment that home-born babies experience. Furthermore, we recognize that achieving hygienic delivery and keeping the cut umbilical cord unexposed to pathogens is nearly impossible in the vast majority of these facilities, where basic necessities such as running water and electricity are often lacking. Even in tertiary care hospitals in large cities we know that exposure to invasive organisms is frequent, and nosocomial infections in babies are hard to prevent without active interventions.
“Chlorhexidine (CHX) is a broad-spectrum antiseptic, effective on gram positive and gram negative bacteria as well as some viruses, having strong skin binding effect. Randomized controlled trials conducted in South Asian countries have proven that the use of chlorhexidine for cord care can reduce neonatal mortality by 23% and prevent severe cord infections by 68%. The study also revealed that an estimated 1 in 6 neonatal deaths could be averted with chlorhexidine cord care” (Steve Hodgins, 2013).
In late 2011, Nepal became the first country in the world to introduce chlorhexidine for umbilical cord care and committed to scale its use nationwide. This was possible because of the strong, committed government leaders, implementation partners, professional societies, and the private sector who all worked together to translate those research findings into action.
In 2011, JSI received a Saving Lives at Birth, Transition to scale up grant. With the catalytic funding from Saving Lives at Birth, JSI has worked closely with the Government of Nepal, and other partners, to scale up the use of Chlorhexidine (CHX) to reduce neonatal mortality due to infections.
Now, as CHX use is part of essential newborn care in the government program, it has been scaled up national wide. It is estimated that by March 2019 this intervention had saved at least 12,000 newborn’s lives. Nepal’s 2016 Demographic Health Survey revealed a neonatal mortality rate of 21/1000 live births, the first decline in 10-15 years, and part of this success can be attributed to CHX use. Nepal became a living university for chlorhexidine, and to date more than 20 national delegations have visited the chlorhexidine program and the Nepal team has provided technical assistance to introduce a Chlorhexidine program in about 20 other countries with high neonatal mortality.
Key lessons learned from the Nepal program are:
- Engage, inform, and win over key gatekeepers and opinion leaders. Foster and support champions who are well placed to influence opinion and decision-making; engage potential local pharmaceutical producers—early.
- Understand and work competently through local policy and regulatory processes, both formal and informal. From the beginning, fully inform and elicit concerns from key government counterparts and opinion leaders.
- Ensure 4% CHX registration as an over-the-counter, not prescription, product.
- Form a technical working group having Ministry of Health leadership and ongoing meaningful involvement by all key partners in directing the initiative (or incorporate the mandate into an existing working group, if one already exists with suitable membership and mandate, e.g., a Ministry-led newborn health or safe motherhood working group) and ensure effective functioning—on a sustained basis (with regular meetings, action points, follow-up).
- Conduct formative research to understand the potential user’s current practices, perspectives, and preferences with respect to appropriate care of the newborn cord stump.
- Start where the user is now, “bridging from the known to the new”, for example using formulation and packaging that resemble current products used for cord application.
- Develop and promote simple approaches and messages. For example, day-of-birth-only application, if appropriate.
- Use existing channel and do not create a vertical approach.
- Enlist private providers and NGOs as appropriate.
- Add chlorhexidine to clean delivery-kit programs, if they are already reaching large numbers.
- Secure long-term arrangements for procurement of a quality product and ensure adequately robust supply chain.
- Address provider skills, attitudes, and behavior for ultimate large scale.
- Do not rush: Start with a learning phase, implementing at limited scale, but under conditions closely approximating what you would expect when institutionalized and running as a normal program. Rigorously monitor during this phase, and then, based on what has been learned, revise and streamline the approach for at-scale implementation.
- Maintaining high coverage at scale specially in hard to reach areas
- Assuring the quality of the CHX product by different pharmaceutical companies
- Assuring the quality of routine information systems
- Ensuring timely supply of CHX through government system