“We shall count it as a part of kyogero”. The acceptability of chlorhexidine for umbilical cord care in the cultural context of Central Uganda
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Background: Over 40% of the 6 million deaths in children under 5 occur in the newborn period. Infections account for a quarter of all newborn deaths. The umbilical cord has been identified as a major route of newborn infections. Application of chlorhexidine on the umbilical cord has been shown to reduce newborn infections and deaths in some settings. Chlorhexidine needs to be applied exclusively to avoid the re-introduction of microorganisms after chlorhexidine application. A randomised controlled trial (RCT) to determine the effectiveness of chlorhexidine application on the cord at birth is currently being implemented in Central Uganda. We conducted a formative qualitative study in the same area to explore the meanings and practices attached to the umbilical cord, and the acceptability of using chlorhexidine only in the care of the cord of the newborn. Methods: The study was designed to inform the design and interpretation of the RCT. The study was composed of two parts. The first part explored the meanings and care of the umbilical cord, while the second part explored the acceptability of chlorhexidine for umbilical cord care. In total, 52 in depth interviews and 7 focus group discussions were conducted with mothers of infants, health care workers, traditional birth attendants and other caregivers. Findings: The umbilical cord had a central symbolic position in newborn care. The way it was handled had far reaching consequences for the survival and wellbeing of the baby. At the same time, the cord was a centre of anxiety as a possible gate to illness, but also as a test of fatherhood and a signifier of parental responsibility. Hence, the cord and the way it was cared for played a part not only in the survival of the baby, but also the survival and wellbeing of the household. In this context, kyogero, a local herb mix was used and reused several times to bath the newborn and clean it both physically and ritually during the first weeks after birth. The introduction of chlorhexidine for cord care was accepted as complementary to kyogero. While chlorhexidine was seen to have a desirable local effect on the cord itself reducing its foul smell and reducing abdominal colic, it did not facilitate the highly desirable early cord fall off and could not replace the symbolic functions of kyogero and its place in securing the overall wellbeing and blessings of the child and the household. Conclusion: The introduction of chlorhexidine for cord care in Central Uganda needs to take the local meanings and practices of cord care into account. Whereas participants were willing to adopt chlorhexidine, they were not willing to abandon the washing of the newborn in kyogero. The future success of chlorhexidine use on cord care may depend on negotiations between the health workers and the mothers’ decision-making circles on the possibility to defer the kyogero bathing until after umbilical cord fall off. In that way both the concern for hygienic cord care and the concern for the wider ritual functions of kyogero can be accommodated.