Evaluation of the Effectiveness of a Community-Based Behavior Change Campaign in Haiti: Newborn Umbilical Cord Care

Great strides in reducing under-five mortality have been made globally since 1970. The reduction of under-five mortality is occurring at a faster rate now than any other time within the past 20 years. Still, approximately seven million children under the age of five died in 2012 with 99% of these deaths occurring in low- and middle-income countries (WHO, 2014a). The proportion of under-five childhood deaths occurring within the first month of life in 1990 as compare to 2012 has escalated from 37 percent to 44 percent respectively even though the prevention of most neonatal mortality is possible (UN, 2014b). One of the greatest coverage gaps in fulfilling the Millennium Development Goals’ health agenda for children includes addressing interventions to prevent neonatal mortality (Requejo et al., 2014).

Sepsis is the third leading cause of neonatal death worldwide (WHO, 2014b). Bacterial infections originating in the umbilical cord (omphalitis) can lead to sepsis and neonatal death (Faridi, Rattan & Ahmad, 1993; Mir et al., 2011; Mullany et al, 2007). Simple affordable interventions are available and may prevent such deaths (Countdown, 2013; Mullany et al., 2006b). In low-income countries, the use of daily applications of 7.1% chlorhexidine digluconate, a topical antiseptic delivering 4% chlorhexidine, to the newborn’s umbilical stump during the first week of life can decrease omphalitis and the risk of developing neonatal sepsis (Arifeen et al., 2012; Imdad et al., 2013; Mullany et al., 2006b; Sazawal et al., 2012b; Soofi et al., 2012). The World Health Organization has recommended the application of 4% chlorhexidine to the umbilical cord stump of infants delivered in the community setting in low resource countries since 1999 (WHO, 2013).

The benefits of chlorhexidine use may be particularly important in Haiti (Walsh, S. et al, 2015). Haiti is the poorest country in the Western Hemisphere, with 62% of the population living on less than $1.25 (US) a day. Haiti’s neonatal mortality rate is 25.5 per 1000 live births compared with less than 3 per 1000 live births in North America and 13.6 per 1000 in the Dominican Republic, Haiti’s island neighbor (UNICEF, 2013). In Haiti, neonatal mortality accounts for one-third of the under-five deaths with 6 % of these newborn deaths caused by sepsis (WHO, 2014c).  Although more than 90% of women in Haiti receive at least one antenatal visit, approximately 63 % of deliveries occur at home (UNICEF, 2013). Compared with institutional births in developed countries, evidence suggests that home births in low income countries incur a higher risk for cord infection (Imdad et al., 2013).

Local cultural beliefs can have a strong influence on cord care practices including unhygienic and traditional cord care practices common in low-resource settings (Herlihy et al., 2013; Smith, 2009; Walsh, S., et al, 2015 ).  Several studies have sought to understand implications for chlorhexidine use among mothers and health workers in Bangladesh, Nepal, Pakistan, Tanzania and Haiti (Alam et al., 2008; Alper, 2007; Arifeen et al., 2012; Imdad et al., 2013; Mullany et al., 2006 a,b; Mullany et al., 2007; Sazawal et al., 2012b; Soofi et al., 2012; Walsh, S. et al, 2015). A number of unhygienic substances such as goat scat, dirt/dust, burnt nutmeg and cotton, crushed charcoal, ash, palm oil, recipe of leaves were reported in Petit-Goâve, Haiti as substances used for neonatal cord applications (Walsh, S. et al, 2015). Similar substances were applied to the neonates’ cords over 50% of the time in Sylhet District, Bangladesh (Alam et al., 2008). The application of mustard oil and other potentially unclean substances to the umbilical cord increases cord infection; one study conducted in Southern Nepal indicated an increased neonatal cord infection risk from 29% to 62% (Mullany et al., 2007).  The effectiveness of chlorhexidine to prevent omphalitis is likely to decrease if such traditional cord care practices are not restricted (Alam et al., 2008; Mullany et al., 2006a).

We previously explored cord care practices and demonstrated a potential acceptability for introducing a new cord care practice such as chlorhexidine use in Petit-Goâve, Haiti (Walsh, S. et al, 2015). We then sought to evaluate the effectiveness of a community-based behavior change campaign among women who deliver at home with a traditional birth attendant (TBA). This campaign aimed to increase the proportion of women who apply chlorhexidine to their newborn’s umbilical cord daily for the first 7 days after birth while preventing the application of unhygienic substances to the umbilical cord during the first 4 weeks after birth.  We used a controlled trial in Petit-Goâve, Haiti to evaluate this campaign which was based on the recommendations made by the World Health Organization (WHO) for newborn care (WHO, 2013).

The setting for the campaign was in Petit-Goâve, Haiti, a district served by Global Health Action (GHA), a non-profit organization that conducts community-based health and development programs in Haiti (GHA, 2014).  GHA trains and supports TBAs, who assist in approximately 900 home-based deliveries annually, and Community Health Workers (CHW), who visit mothers and neonates during the post-partum period. Eligible women were greater than 18 years of age and experienced an uncomplicated delivery by a TBA and gave birth to an apparently healthy baby who was one week of age (n ≈ 200). Our intervention group included mothers who received prenatal care from the nurse at the local community clinic who had been trained in the WHO cord care protocol. A natural occurring comparison group were mothers who delivered within the catchment area of the trained TBAs who either received antenatal care at a facility other than the community clinic or did not receive any antenatal care. A verbal questionnaire was given to the consenting mothers at 1 week post-delivery, following the CHW’s routine newborn assessment. A second questionnaire was given when the infant was 4 weeks of age.

[Data collection and analysis to be completed 6/2015] Descriptive statistics and unadjusted and adjusted analyses will be used to determine the differences in the mother’s cord care practices between the intervention and control groups. Preliminary data (N=80/200) indicate compliance with chlorhexidine application and an absence of other topical substances used. However cloth coverings were frequently applied. Potential implications include recognition of traditional beliefs and practices of newborn cord care being essential to ensure acceptability of a new cord care practice to reduce neonatal cord infections. Haitian mothers and local caregivers appear willing to adopt a new cord care practice. An important cultural consideration to the campaign might include directives for clean cloth cord coverings. If a non-traditional cord care practice delivered by community health providers is successful, this strategy can be used for improving other aspects of newborn care.