Exciting new evidence has bolstered our fight against one of the top three causes of newborn deaths around the world. Each year approximately 1 million newborn babies lose their lives to largely preventable severe infections, accounting for nearly one third of the total burden of newborn deaths. Most of these lives could be saved by improving hygiene and reducing exposure to life-threatening bacterial infections particularly in the first week of life, and by making antibiotics available to newborns who become sick.
Research published this week in The Lancet confirms that a simple solution can prevent newborn infections and dramatically reduce newborn deaths. Findings from studies done in Bangladesh and Pakistan show that when chlorhexidine, an inexpensive and widely available antiseptic, is applied to the newborn’s umbilical cord at home and soon after birth, neonatal mortality can be significantly reduced. The two studies support earlier findings from a field trial in Nepal which showed a 24% reduction in newborn mortality when community health workers applied chlorhexidine to the cord during home visits.
Chlorhexidine has been used as an antiseptic for decades, ranging from use in oral rinses to surgical prep, and has an excellent safety record. Hospitals in the US and other developed countries already use it to prevent umbilical cord infections. But in developing countries, where the majority of births happen at home and in communities where poor hygiene leads to very high newborn infection and death rates, there is little experience with – and evidence for – chlorhexidine cord cleansing. In fact, cord care practices in many developing countries are steeped in cultural and religious traditions, and involve putting a number of different harmful substances on the cord. Unfortunately many of these practices greatly increase exposure of the umbilical cord to bacteria that cause fatal infections.
The only global approach to combat this problem has been the 1998 WHO recommendation to put nothing on the cord, a message to families that sought to avoid any harmful substance being applied that could increase the risk of infection. The studies’ hypotheses that using chlorhexidine in settings where hygiene was undoubtedly poor would reduce rates of cord infection and neonatal mortality when compared to the standard dry cord care approach, made much sense. Furthermore, soaking the cord with a cotton ball dipped in chlorhexidine could be simply done at home by the newborn’s family, any caregiver or community health worker.
The two new trials tested somewhat different approaches for getting chlorhexidine on the cord. In Bangladesh, local women volunteers made home visits as early as possible after birth to apply chlorhexidine to the newborn’s cord, and then, in one arm of the study, continued to make these visits over the first 10 days of life. In Pakistan, traditional birth attendants (TBAs), who often assist women during home deliveries, applied the first dose of chlorhexidine just after birth, teaching the family and instructing them to continue this practice once a day for 14 days.
Both country results prove that this simple intervention significantly reduces newborn deaths. Findings from Bangladesh were somewhat mixed, showing that chlorhexidine cord cleansing on the first day of birth reduced newborn death by as much as 20%, but chlorhexidine treatment for 7 days, although showing fewer signs of infection when compared to dry cord care, did not see a significant reduction in newborn mortality. The Pakistan study found that when chlorhexidine was recommended and provided by TBAs to families, risk of newborn infection dropped 42%, and neonatal mortality reduced by nearly 40%.
One important point is that chlorhexidine seems to work best to save newborn lives if applied early, particularly on the first day of life. Based on the new evidence, we know there are at least 2 ways of doing this:
- Make chlorhexidine and instructions for use right after birth available to families before childbirth; or
- Ensure a home visit on the first day of life by a community health worker or volunteer
These are certainly doable approaches in most developing countries where infections claim thousands of newborn lives each year, so what are the next steps?
Bringing together leading experts, government health officials, advocates and other stakeholders to review the evidence and plan how to go about introducing chlorhexidine cord cleansing is a good first step. Local evidence will be needed to find the best ways to ensure chlorhexidine is properly applied to the cord, especially on the first day. Stakeholders will need to feel comfortable that chlorhexidine will work in their contexts in order to change policies and introduce at large scale.
So far, it is clear that in communities in Asia, chlorhexidine cord cleansing prevents infections and saves newborn lives. If trials in Africa – two are currently underway – confirm the effectiveness of chlorhexidine, we can expect a major change in global recommendations.
Nevertheless we have in hand now the evidence we need to introduce and scale up chlorhexidine cord cleansing in Asia, saving thousands of newborn lives.
Photo: Bangladesh, by Shafiqul Alam Kiron / Save the Children