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Awareness and Practices of Women of Reproductive Age regarding the Use of Chlorhexidine for Newborn Cord Care in a Selected Community in Jos South Local Government Area, Plateau State, Nigeria

Background: Neonatal mortality remains a public health concern in subSaharan Africa especially in Nigeria and poor cord care is a major contributor to the high neonatal mortality. The objective of this study was to assess the awareness and practice of Chlorhexidine cord care by women of reproductive age in Jos South Local Government Area of Plateau State. Methods: This was a community based descriptive cross sectional study carried out among women of childbearing age in Lwellem Community of Jos South Local Government Area. A structured interviewer-administered questionnaire was used to obtain information from respondents who were selected through total population sampling. Data was analyzed using Statistical package for the Social Sciences version 20. Results: Three hundred women with children aged less than 5 years were administered the questionnaire. Two hundred and ninety seven (99%) were of low socio-economic status, 71 (23.5%) were farmers, 75 (25%) were traders and 60 (20%) were not gainfully employed. One hundred and sixty seven (55.6%) mothers were uneducated, 286 (95.3%) attended antenatal care during their last pregnancy and 78 (26.0%) were aware of Chlorhexidine use for newborn cord care with 89 (29.6%) using it. One hundred and sixty eight (56.0%) women practiced cord care to hasten falling of the cord and 85 (28.3%) practiced it to prevent infection. Conclusion: There is low awareness and use of Chlorhexidine for cord care in newborns. Women of reproductive age in this community should be educated on the use of Chlorhexidine cord care for newborns to reduce neonatal morbidity and mortality resulting from cord sepsis due to poor cord care practices. Key word: Chlorhexidine cord care, Neonates, awareness, utilization Journal of Epidemiological Society of Nigeria Vol. 3 No.1 June. 2020 53-61

newborn deaths that occurred. Infections (36%) have been reported to be the major cause of neonatal death and neonatal deaths account for 40% of deaths under the 4 age of 5 years worldwide. This is more so in northern Nigeria where neonatal 5 mortality stands at 44/1000 live births.
The three major causes of neonatal death (infections, complications of preterm birth, and intrapartum related neonatal deaths) account for almost 90% of all 6 neonatal deaths. To curb this trend in developing countries, the World Health Organization (WHO) in 2013 enlisted the use of antiseptic solution as means of clean cord care practices to reduce neonatal 6,7 mortality and morbidity. Studies across the globe and particularly in sub-saharan Africa showed Chlorhexidine, when applied to the umbilical cord, is effective and efcient in reducing neonatal sepsis in high-risk settings, resulting in over 68% reduction in severe infection and a 23% (8,9) reduction in all cause neonatal mortality.
In 2016, a community based randomized trial was conducted in Tanzania to compare the use of Chlorhexidine for cord care with dry cord care in babies between 1 -48 hours old. The result showed that the n e o n a t a l m o r t a l i t y r a t e w a s n o t signicantly lower in the Chlorhexidine 10 group than in the dry cord care group. Neonatal sepsis and prematurity have emerged as principal challenges to reduction in neonatal mortality and 19 morbidity. Poor hygienic umbilical cord care in the rst week of life is a welldocumented risk factor that increases the [20][21][22] likelihood of neonatal infections. The knowledge of women of reproductive age on good cord care is vital. Their awareness and use of chlorhexidine for cord care is imperative not only to scale up its use but also to reduce the high neonatal mortality in this environment. The objective of this study was to determine the awareness of Chlorhexidine and its use for newborn cord care by women of reproductive age in Jos South LGA of Plateau State

Methods
This was a community based descriptive study carried out among women of reproductive age in Lwellem villages of Tanchol ward, Gyel District, Jos South Local Government Area, Plateau State, Nigeria. A structured questionnaire adapted from USAID/TSHIP project 2013 -2015 was used to obtain data on age, place of antenatal care and birth, treatment applied to the cord stump and the socioeconomic status of the mothers. A total population sampling was done. The minimum sample size was calculated using Taro Yamane formula with 95% 2 3 condence interval shown below. Ethical clearance and permission were obtain from the Bingham University E t h i c a l C o m m i t t e e a n d r e l e v a n t authorities at Lwellem settlement of Tanchol ward, Gyel district, Jos South Local Government Area of Plateau State, Nigeria.

Results
The socio-demographic distribution of mothers of under ve children shows that the largest age group was between 25-29 years; 86 (28.7%) and the lowest age group 45 -49 years; 9 (3.0%). The respondents with primary education or below were 167(55.6%) while 133 (44.3%) had secondary and above. Majority of the mothers were traders; 75 (25%) and farmers; 71 (23%). On the average, most (51.7%) women in the community had had at least 4 deliveries. Table 1.
Two hundred and eighty six (95.3%) mothers attended antenatal care but only 2 6 . 0 % o f t h e m w e r e a w a r e o f Chlorhexidine being used for cord care. Most; 168 (56.0%) mothers practiced cord care for the purpose of hastening falling off of the cord and only 85 (28.3%) of the mothers practiced cord care to prevent infection. Most of the women in the community applied some substances other than Chlorhexidine (29.9%) to clean the cord stump immediately after delivery. Table 2. Table 3

Discussion
The socio demographic data from women of Lwellem community showed the age group 25-29 years had the single highest number followed by the 30-34 years age group. However, mothers at the extremes of the reproductive age group (15-19yrs, 35-49yrs) make up thirty percent of mothers of under ve children in the community. This is similar to ndings from the National Demographic and Health Survey (NDHS) report of 2013, which showed that in Nigeria, the proportion of mothers of under ve children in the extreme groups of reproductive age is smaller than the proportion in the age group of 25-29 years, 17 which results in decline in fertility . Education plays a pivotal role in the k n o w l e d g e a n d u n d e r s t a n d i n g o f childcare. Our study showed that 55.6% of mothers of under-ve children were of low educational level and is in keeping with studies conducted Nepal, Pakistan and Nigeria which showed that educational levels are low in women and this places them at a distinct disadvantage compared to men. Hence, this may in turn lead to a 24, 25, high neonatal mortality and morbidity. 26 Occupation revealed that majority of respondents did not engage in any income generating activities. This agrees with the report of the NDHS 2013 which showed that only 45% of women in agricultural occupation were paid in cash/money while 16 others were paid in kind or not paid at all.
Thus, the women have an economic base that is too weak to provide the required resources for holistic care of their neonates leading to increased neonatal morbidity 17 and mortality.
Data analyzed on the parity of the mothers of under ve children in the Lwellem community showed that the average number of children born to one woman is 4 which is lower than the total fertility rate (TFR) for Nigeria as recorded by NDHS 16 2013. Higher number of deliveries (>5 pregnancies) carry much obstetric complications, hence for the 31.3% grand multiparous women of reproductive age, this raises the concern of maternal m o r t a l i t y a n d m o r b i d i t y i n t h e 17 community. Knowledge of mothers on neonatal and childcare is essential for their proper growth and development. Women are expected to have information and skills for newborn care and recognition of neonatal danger signs during the neonatal period. In this study, a large majority of the women in the Lwellem community attended ANC during their last pregnancy. This is not in agreement with ndings from the 2008 NDHS reports, which showed that in north eastern region, only between 16 -58% of pregnant women received antenatal care from skilled provider.
It is recommended that Chlorhexidine be applied to the cord for all births irrespective of where childbirth takes place. However, in our study, three quarters of the respondents had not heard  signicantly under 5%. We can infer that knowledge of the goal standard of cord care (Chlorhexidine gel/ solution) is poor in this community. This could increase the risk of neonatal morbidity and mortality as various studies conducted in developing countries have shown that chlorhexidine antisepsis interventions may improve 16,17,18,29. neonatal health However, a study conducted in Benin City in 2015 on cord care education given at antenatal clinics showed that health education on cord care is lacking even among well-educated 12 health care workers.
This study found that majority of the mothers applied substances such as saltwarm water, Shea butter, Savlon/gentian violet, vasline etc. to facilitate falling off of the cord implying that majority of the women were more concerned about the cord falling off than preventing infection of the cord. The belief is common in many cultures that the cord should not dry so the practice of applying substances to the cord stump aims to make it soft allowing it to 30 separate and heal easily and quickly. There were similar ndings seen in rural Uganda in 2008, Ghana in 2005 and Nigeria in 2010 where these substances are believed to help the cord to dry and separate faster within 3days and save the neonate from "evil eye" which they 28,29,30 believe causes neonatal deaths. Hence, from this study, the practice of women in the Lwellem settlement on cord care is poor. This may be the result of poor or inadequate knowledge on cord care practices immediately after delivery. Cord care plays a major role in causing neonatal 31 morbidities and mortalities.
Chlorhexidine is poorly used for cord care in this community, meaning that many of the substances and methods used for cord care are based on traditional beliefs which are often interwoven with witchcraft, magic and taboo as reported in the LiST model, 2010. Here women were found to use charcoal or cow dung to dress the 32 umbilical cord of neonates. A study conducted in Uganda showed that over 50% of the mothers applied various substances to the cord stump of their babies 33 to quicken the healing. This agrees with our study which showed mothers practice cord care to facilitate drying off of cord. However, only a few of the mothers in this study practiced cord care to prevent 33 infections.

Conclusion
This study found low awareness and poor utilization of Chlorhexidine for cord care i n n e o n a t e s a m o n g m o t h e r s o f reproductive age in Lwellem Community. Women of reproductive age should be educated on the importance of the use of Chlorhexidine gel/solution for the cord care of their neonates.

Acknowledgement
The authors are grateful to the participants w h o c o n s e n t e d a n d p r o v i d e d t h e information needed for this study. We also thank the community leaders for their commitment and sacrices in ensuring that their community participated in this study.

Conict of interest:
The authors declare that there is no conict of interest of any form.