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Table 2 Articles included in this review, with cord care practices

From: Umbilical cord-care practices in low- and middle-income countries: a systematic review

First author Journal Country Purpose of study and overall cord care practices (if stated) What substance was applied to the cord
Abhulimhen-Iyoha [12] Niger J Clin Pract. 2012 Nigeria A study to determine the factors that influence cord care practices among mothers in Benin City, Nigeria. Beneficial cord care (as defined by study authors): methylated spirits (20.5%), or non-beneficial substances: hot compress, herbs, native chalk, salt, sand, saliva, palm oil, menthol-containing balm, petroleum jelly, and toothpaste (substances were used alone or in combination and mainly applied at home) (76.9%).
Adejuyigbe [30] Matern Child Nutr. 2008 Nigeria Study examines differences in feeding and care between low-birthweight and normal-weight newborns. It is no clear from the article whether the cord care practices mentioned were specific to low-birthweight babies. Fomentation with dry heat, application of white powder, and bandaging to prevent infection.
Alam [54] J Perinatol. 2008 Bangladesh An assessment of umbilical and skin care knowledge and practices for neonates in Sylhet District, Bangladesh. A boiled or new blade was used in over half the births (64%). Half of the families applied a substance to the cord. Turmeric (83%), boric powder (53%), mustard oil, ash, Dettol, coconut oil, Nebanol ointment, ginger, chewed rice. Also practiced shek dewa (heat treatment of cord). Respondents did not indicate any concern about having clean hands or using a clean cloth during shek dewa.
Alhaji [37] Niger Med J. 2013 Nigeria Review of neonatal tetanus cases at Maiduguri Teaching Hospital. Hot fomentation, charcoal, mixed, toothpaste, other.
Alparslan [13] Jpn J Nurs Sci. 2013 Turkey A study to identify traditional neonatal care practices applied by women ages 15 to 49. Cord cutting and tying practices were not discussed. Mothers reported putting something on the cord to make it separate faster, tying the belly with a rope, and also putting a buttered cloth over the infant’s infected belly. This study reports on previous studies from Turkey which identified the following substances placed on the umbilical cord: dry coffee, olive oil, rotten tree powder, myrtle, sugared fat, hellebore, black sesame, and burnt cloth. This study did not inquire about specific substances, but did report that 10.3% of the women put a substance on the cord, 7.2% tied the belly with a rope, and 1.5% put a buttered cloth over the infant’s infected belly.
Amare [14] BMC Int Health Hum Rights. 2014 Ethiopia Investigation of practices and perspectives related to umbilical care in Ethiopia. A new razor blade which is sometimes boiled (22/24 mothers), cord tie varies (sewing thread, thread from kerosene stove, sisal, blanket strips, etc.). Cord is usually cut before delivery of placenta. Application of substance in most cases. Those who did not apply substance were either advised by health workers or said it was not customary (5/24 mothers). Butter, petroleum jelly, hair lotion (Oromia).
Butter or nothing (Amhara).
Butter (Tigray).
Petroleum jelly, hair lotion, or nothing (Sidama).
Iodine or Gentian violet (applied by health extension workers in Oromia and Tigray). One health extension worker in Sidama advised application of tetracycline.
Ayaz [55] PLoS One. 2010 Pakistan A study to understand newborn care practices in a squatter settlement of Karachi, Pakistan. For home births, clean instruments were used to cut the cord in 53.2% of births, 0.4% reported unclean instruments (unclean blade, etc.), and 46.4% did not know. It is assumed that clean instruments were used for facility births. Substances were put on the cord in 57.7% of births regardless of place of birth. Ointment (33%), ghee (27%), coconut oil (19%), mustard oil (9.5%). Some also applied surma (locally made kohl), clove oil, turmeric, and talcum powder.
Byaruhanga [7] Midwifery. 2011 Uganda A study to explore acceptability and feasibility of newborn care practices at the household and family level in rural Uganda. Dry cord care was stated as difficult to follow. Herbs, onions, ash from burnt papyrus, petroleum jelly, powder, saliva, ghee, soot mixed with ghee, surgical spirit, water, butter.
Callaghan-Koru [56] BMC Pediatr. 2013 Ethiopia A study describing newborn care practices reported by recently-delivered women in four regions of Ethiopia. New string was used to tie cord in 46% of births, but fiber from the false banana (ensete) plant was also common. New razor or blade was used in home births to cut the cord 88% of the time and scissors were most commonly used in facilities. Women delivering at home applied a substance 27% of the time. While women who delivered in facilities stated that no substance was applied 47% of the time, 43% did not know if a substance had been applied. Most commonly applied substance was butter. Other substances were applied, but not identified.
Darmstadt [31] Trop Med Int Health. 2007 Egypt Survey of home care practices during the first week of life in three rural Egyptian Governorates. Handwashing is not routine. Three-quarters of infants had a substance applied to their umbilical cords. Cord stump was also frequently covered by diaper. Antiseptic (alcohol was used in 80% of antiseptic applications). Kohl (9%) was also used. Kohl contains lead.
Degefie [16] BMC Int Health Hum Rights. 2014 Ethiopia A study on the beliefs and practices related to immediate newborn and postnatal care in four rural communities in Ethiopia. Cord is typically cut with a new blade. Grandmothers and TBAs rub cord before cutting to prevent blood seeping out (not all wear gloves or wash hands before receiving baby). Cord usually tied with thread. Applications to the cord differ by region. Ointment (Sidama) or butter (East Shewa).
Dhingra [24] BMC Pregnancy Childbirth. 2014 Tanzania An exploration of attitudes, beliefs, and practices related to delivery and newborn care in Pemba, Tanzania. The cord is cut soon after delivery. Clean cutting instrument appeared to be commonly understood among all participants (TBAs generally boil items in water). Cord tied with normal tailoring thread, but a few used special thread provided by the hospital. Cord is usually covered with a cloth to protect it from dust, flies, and mosquitos (and cord and surrounding area of male babies are also covered to prevent cord from falling on genitals). While the practice of dry cord care had reached all levels of society, substances were sometimes applied. Saliva (mate), dirty door powder from old door (ganda la popoo), hot knife, charcoal powder, shells (gamba la koa), PPF powder, burning wood (kijinga), banana steam [sic] (tojo), fish bone. Substances were also applied AFTER cord fell off.
Upon recognition of danger signs: hot knife, door dust, charcoal powder, sandalwood powder, ground sea shell, PPF or talcum powder, and fire steam.
Falle [57] J Health Popul Nutr. 2009 Nepal A study of the practices of traditional birth attendants working in Maithili-speaking (Madeshi) and Nepali-speaking (Pahadi) communities. About 27% of the TBAs reported applying a substance to the cord. New blade was used to cut cord in 89% of deliveries. Remaining 11% were cut with scissors (not clear if they were boiled or sterilized). Mustard oil (64%), saliva (16%), antiseptics (12%).
Geçkil [25] Midwifery. 2009 Turkey A study of traditional cord care practices in southeastern Turkey. Practices included application of a substance, keeping the cord in a special place after it separated, and then discarding it in a place that would create significant meaning for the infant’s future. Olive oil (37.7%), coffee, tar (15%).
Ghosh [58] J Biosoc Sci. 2010 India A study of antenatal, delivery, and postnatal practices of women in India who had experienced a neonatal death compared to current living children and also compared to women who had not experienced a neonatal death. Study showed better care practices for living children. Use of sterilized instrument for cutting cord was high across all groups (75% to 85%). Eight-six percent of the deceased infants had herbal paste or mustard oil applied to their umbilical cords (compared to 64% in the group of women with no neonatal deaths). Herbal paste, mustard oil, other, antiseptic.
Gilani [59] Rural Remote Health. 2014 Pakistan A study to understand practices of mothers in regard to seeking healthcare for neonates in rural and urban settings of the capital district of Azad Jammu and Kashmir, Pakistan. The use of sterilized string to tie the cord was more common in urban areas vs. rural areas (44% vs. 27%). Use of a sterilized or boiled cutting tool was slightly more common in urban areas. Rural place of residence had a statistically significant association with use of unsterilized cutting and tying. Not stated.
Grant [60] Paediatr Child Health. 2014 Uganda Article describes verbal autopsy procedure to determine probably causes of 72 neonatal deaths (30% occurred in first week of life) in Uganda. Sepsis due to infected umbilical cord was identified as the probable cause in 42% of deaths (highest of all identified causes). Herbs, powder of papyrus reeds, soot from cooking pot, and saliva.
Gul [34] Int J Health Sci (Qassim). 2014 Pakistan A study to understand newborn care knowledge and practices among mothers in urban Pakistan. In 60% of home deliveries a new razor was used to cut the cord and 10% recalled the use of a household knife. Seventy-four percent (74%) or respondents applied a substance to the cord. Coconut oil, mustard oil, ghee, olive oil, surma/kohl, turmeric, machine oil
Herlihy [8] PLoS One. 2013 Zambia A study to understand local perceptions of cord health and illness and the beliefs that shape cord care knowledge and practices. The cord was most frequently tied with white or black cotton knitting wool (home) or clamps (facility). In an emergency, women would use part of their chitenge (traditional fabric wrap). Traditional practice no longer used is the tying of the cord with loozi (fiber from the bark of a tree).
A razor blade was the tool of choice for cutting the cord at home or scissors in a clinic. Despite the HIV epidemic, traditional healers and TBAs rarely sterilized tools, but CHWs and midwifes reported some type of disinfection (boiling or alcohol).
Different substances had different purposes. If cord is too brittle, cracking, bleeding, then a substance that increases softness (Vaseline®, cooking or motor oil, mabono (wild fruit) oil, or cream from sour milk). While warmed cooking or motor oil were rare, they were sometimes used as a base for other ingredients (charcoal, herbs).
If cord takes too long to separate, items to dry it include: baby powder, charcoal dust, dried cow dung, dried chicken droppings, dust from threshold of home, ash from burnt pumpkin stem, crushed loma (wasps nest), or mud. Any of these would be pounded or ground into a fine powder.
Medicinal substances: breast milk, python snake oil, banana, cow dung, mukunku (tree bark), traditional herbs, and dirt from pounding stick.
Hill [15] Pediatr Infect Dis J. 2010 Ghana A study exploring delivery practices in Ghana. The cord is generally cut with new razor blade (98%) and tied with new thread (90%), but dry cord care (the standard) was only practiced 8% of the time. Hospital medicine (spirit) (31%), shea butter (47%), herbs (5%), other (16%). Also common to drip hot water on stump or apply a hot damp towel.
Jennings [61] Matern Child Health J. 2015 Benin A study focused on use of job aids to improve facility based postnatal counseling. The only discussion regarding cord care was in regard to substances applied. Traditional substances include clay, ash, salt/spices, ground almonds.
Karas [62] J Trop Pediatr. 2012 Nepal An analysis of newborn care practices as part of a community-based trial investigating clean birthing kits. Although 97.7% of participants used the new razor blade with the kit, authors note that this is not customary practice. 95% waited until placenta was delivered to cut cord. Substance was applied to 18.8% of cords. Mustard oil, antiseptic, ash, mud, other (other oil, breast milk, herbs/spices, saliva, and other substances).
Kayom [9] Int J Pediatr. 2015 Uganda A study to investigate newborn care practices in urban Uganda. Almost 70% of mothers had received teachings on cord care, but only 45% of those were from health professionals. Majority (89.6%) cleaned the cord twice a day. About 58% of the mothers in the study applied a substance to the cord. Salty water, powder, Vaseline, spirit, normal saline, ripe banana (gonja), sap, soot, ash, saliva, herbs.
Kesterton [63] BMC Pregnancy Childbirth. 2009 India A study to understand local practices in rural Karnataka, India to improve implementation of essential newborn care practices. A sickle was used in about 1/3 of home births and a used blade in a majority of others. A substance is applied to the cord in some cases. Turmeric, burning tip with castor oil lamp, antiseptic ointment.
Khadduri [33] J Perinatol. 2008 Pakistan A study to learn about maternal and newborn health knowledge and practices in rural Pakistan. A used blade, knife, or scissors was used often. The TBAs claimed to have washed the implements, but the mothers and father asserted that their TBAs had not washed the cutting instrument. Substances are applied to the cord using an uncleaned chicken feather either from the ground or freshly plucked. Ghee and sometimes a paste of ghee with fried onions or mustard oil.
Khan [10] J Neonatal Perinatal Med. 2013 Pakistan A study to explore traditional newborn care beliefs and practices in Gilgit, Pakistan. The cord was cut with scissors (most common), blade (28%), or knife (5%). The cord was tied with available thread (55%) or a cord clamp (43.6%). The majority of households (77%) applied a substance to the cord. Matti (crushed apricot seeds), cold cream, ghee, haldi (turmeric), mustard seed oil, Dettol, powder/wheat flour, antimony.
Kumar [64] Lancet. 2008 India Study conducted as part of a three-arm cluster randomized trial (control, newborn care package, and newborn care package + thermospot). Evaluated tying cord within 1/2 h of birth, cutting cord within 1/2 h of birth, cutting cord with clean blade, re-tying cord, application of substance on the cord and on the body. Ash or clay on cord (60.9% of control group, 38% of ENC group, and 36.1% of ENC + TS group).
Madhu [32] Indian J Community Med. 2009 India A study to describe breastfeeding and other newborn care practices in rural Bangalore, India. In the small number of home deliveries (10% of total), a household knife was used to cut the cord in half (5 deliveries). Thirty-three percent of total births had something applied to the cord (regardless of place of birth). Talcum powder or turmeric.
Mangwi Ayiasi [65] PLoS One. 2016 Uganda Study compared the effect of village health team (community health workers) visits and mobile phone consultations on maternal and newborn care practices. In the intervention group 60% of women used clean cord care practices while only 30% in the control group. Baby powder was the most prevalent substance applied to the cord, followed by soot powder, herbal medicines, and animal dung.
Memon [66] J Neonatal Perinatal Med. 2013 Pakistan A study to assess knowledge, attitudes, and practices of women of reproductive age in rural Pakistan. Sixty-nine percent of participants applied a substance to the umbilical cord. Mustard oil (54.4%), antimony (20.5%), and clarified butter (1.8%).
Moran [16] BMC Pregnancy Childbirth. 2009 Bangladesh A study to describe newborn care practices in the urban slums in Dhaka, Bangladesh. The cord is usually cut with a new or boiled blade. Thread used to tie the cord was generally not sterile. After cutting cord women reported cleaning the stump and surrounding areas (with wet cloth and soap or antiseptic liquid) and then applying heat and/or a substance to the cord. Mustard oil, mustard with chopped, smashed garlic, coconut oil, boric powder, talcum powder, Savlon, chular mati (earth from a clay oven), homeopathic medicine. Also practiced shek dewa (heat treatment).
Moyer [21] BMC Pregnancy Childbirth. 2012 Ghana A study exploring clean birth practices and immediate newborn care in Ghana. The cord is typically cut with scissors or razor blade. Unprompted, women described the importance of sterilizing the tool. Cord was tied with rags, twigs, linen, string, rope, or plastic clamp. Substance were applied by 70% of women in the sample despite advice from providers to apply nothing. Shea butter, ground shea nuts, local herbs, local oil, or “red earth sand”. Another person described application of juice from pou plant, spirits. Healthcare provider described practices no longer in use of using cow dung.
Mrisho [23] Trans R Soc Trop Med Hyg. 2008 Tanzania A study to understand childbirth and neonatal care practices. The cord usually cut with razor blade and tied with thread (or sometimes cut with millet stem). Razors generally not new. Substance applied to cord. Traditional herbs + cooking oil or water that has been used to wash an adult woman’s genitals (numbati). Other substances include ash, breast milk, fluid from pumpkin flowers, and powder ground from local tree.
Mullany [67] Am J Epidemiol. 2007 Nepal An analysis of data on potential risk factors for omphalitis as part of a community-based, umbilical cord care trial. Substances were applied to the cord during the newborn period. Sometimes multiple substances were applied. Mustard oil (80.4%), ash (7.1%), mud (6.8%), other substances (5.5%), non-study antiseptics (15.4%).
Mullany [26] Pediatr Infect Dis J. 2009 Tanzania Part of a larger clinical trial evaluating a suite of antenatal regimens and use of clean delivery kit in Tanzania. The cord was cut with items from a clean delivery kit. The study looked at two different definitions of cord infection (a broad definition and restrictive definition). Substances were applied to the cords in 10% of cases (home births only). Dust, spirits/antibiotics, baby powder, charcoal, saliva, bark, vegetable oil, and dried roots; most common application was saliva.
Raza [36] J Postgrad Med. 2004 Pakistan Matched case control study of 125 cases of neonatal tetanus reported by 2 hospitals in Karachi between January 1998 and February 2001. There were 125 cases and 250 controls. Each case had two controls matched on gender, area of residency, time of birth within 2 months of case birth, and survived neonatal period and mothers had no history of tetanus toxoid immunization. Mustard oil, ghee, surma (contains antimony and lead).
Sacks [18] BMC Pregnancy Childbirth. 2015 Zambia A study to understand local practices during the postnatal period. TBAs reported that they try to buy a new blade, but if there is no time to prepare then they use an old blade. Substances applied to the stump vary by whether child is classified (at birth) as “sick” or “healthy”. If there are blood clots in the umbilical cord, a sign of abnormality and future illness, the child is taken to a healer who treats the stump with herbs or the child is taken to a hospital. Until the cord separates, mother is expected to apply a wrap around the infant’s waist so that the cord does not touch the genitals (will make them infertile as an adult) and the cord is not supposed to fall on to the floor. Once the cord separates, the baby is bathed in cold water to make them strong. Breast milk dripped onto cord.
Full-term healthy babies: black powder (made from burn stem of pumpkin).
Pre-term babies: green powder (ground dried roots of mweeye plant). This is considered gentler for preterm babies.
If the appropriate herbs cannot be found then brick ash is used.
Less common: after the cord falls off, fresh dried chicken dung is mashed and put onto the wound (rooster for male babies, hen for female babies). Participants explained that this tradition originated in Zimbabwe.
Shamba [19] J Health Popul Nutr. 2013 Tanzania A study to explore childbirth-related hygiene and newborn care practices in community deliveries in southern Tanzania. New blades were used in almost all instance, but new cord ties were rarely used. Substance was applied to cord by many mothers. Breast milk, talcum powder, oil, petroleum jelly, ash, and dirt.
Sharkey [11] Health Policy Plan. 2016 Sierra Leone A study to understand maternal and neonatal care practices in four rural districts of Sierra Leone. Pounded cassava.
Sharma [28] BMC Pregnancy Childbirth. 2016 Nepal A study to understand beliefs around childbirth and postnatal card in rural Nepal, particularly focusing on beliefs related to women being polluted following childbirth. A hasiya (scythe), a sickle, or a razor blade may be used to cut the umbilical cord and then a substance may be applied. Antiseptic, cooking oil, ghee, plain water, toothpaste, and ash.
Sreeramareddy [68] BMC Pregnancy Childbirth. 2006 Nepal A study to understand reasons for delivering at home and about newborn care practices in urban areas of Nepal. The umbilical cord cut after delivery of placenta in 64.2% of cases, cut with new/boiled blade in 90.4% of cases (sickle, old knife, unboiled blade in 7.1%), no substance applied in 73.8% of cases. Newborn wrapped in old, washed cloth in 73.8% of cases. Mustard oil (19.6%), oil + turmeric (2.1%), antiseptic (0.8%), unknown (9.6%), nothing applied (67.9%).
Upadhyay [29] Acta Paediatr. 2012 India A study to document neonatal care practices in the home and their associate with birth-attendant type. The cord was cut immediately after birth (50.6%) and cut after delivery after placenta in 29.6% (cutting immediately after birth was more common in skilled birth attendant deliveries). Clean instrument used in 70% and sterile tie used in 90%. Cord stump left dry in only 26.7%. Antibiotic powder (46.4%), oil/ghee (42.8%).
Waiswa [20] BMC Pregnancy Childbirth. 2008 Uganda A study to explore the acceptability of evidence-based interventions to reduce maternal and newborn mortality in two rural districts in Uganda. Cord is usually cut with a new razor blade. Substances are applied. Baby powder, spirit, herbs, soapy water, salty water.
Waiswa [69] BMC Pregnancy Childbirth. 2010 Uganda A study to explore the socioeconomic differences in the use of newborn care practices in Uganda. Most cords were cut with a clean razor blade and cords were tied with clean thread in the majority of cases. Half the mothers applied a substance to the cord. Powder, surgical spirit, salty water, lizard droppings, ash, medicinal drugs.
Walsh [22] Glob Public Health. 2015 Haiti An exploration of current cord care practices in Petit-Goâve, Haiti. The cord needs to be covered by a cloth or substance to protect against evil spirits. Burnt nutmeg, dirt from threshold of home, crushed charcoal, ash, burned cotton, palm oil, mixture of leaves and animal dung.
Winch [27] Lancet. 2005 Bangladesh A study to describe the beliefs surrounding the neonatal period in Sylhet District, Bangladesh. The cord is usually cut with a blade and then tied with a white thread, and then a substance is applied. Chewed turmeric, chewed ginger, mustard oil with garlic, ash. Shek dewa (heat treatment) is also practiced.
  1. Abbreviation
  2. TBA traditional birth attendant