Percent of newborns with nothing harmful applied to cord (for home and facility deliveries)

The percentage of most recent births during a specified time period delivered at home or in facilities where the newborn had nothing harmful applied to the umbilical cord after cutting and tying.

This indicator is calculated as:

(Number of most recent live births with nothing harmful applied to cord / Total number of most recent live births during a specified time period) x 100

Data on newborn cord care practices for most recent births from population based surveys such as Demographic Health Survey (DHS) and the UNICEF Multiple Indicators Cluster Survey (MICS) or from newborn care program surveys and reviews of facility delivery records. Generally DHS uses a recall period of five years and MICS uses a two year period. Data for calculating this indicator can also be collected through surveys of facilities and direct observation of providers in facilities. Data can be disaggregated by home versus facility deliveries, type of facility (e.g., public, private, non-governmental organization) and other factors such as district or urban/rural location.

Population based surveys such as DHS and UNICEF/MICS; program surveys; direct observation in facilities, reviews of facility delivery records.

This indicator assesses whether newborns had nothing harmful applied to their umbilical cords after cutting and tying, which is a core component of recommended clean cord care at delivery, and can be used as a measure for the quality of and adherence to service protocols, performance of birth attendants, and adoption of newborn care messages at the community level (Gage et al., 2005). Where a national policy on cord care of newborns exists, this can be used as a standard against which to assess the practices of health care providers. Clean cord care is one of five ‘Best Practices’ for all newborns: (1) Keeping the newborn warm to prevent hypothermia; (2) cord care; (3) eye care; (4) promotion of exclusive breastfeeding within one hour; and (5) routine immunizations (WHO, 2003). Clean cord practices, including keeping the cord stump clean and dry, are essential to preventing cord infections, the occurrence of which are at highest risk in the first three days of life.  In some cultures, substances such as clarified butter, cow dung, ashes, or herbal pastes are placed on the cord and increase the risk of infection (Save the Children, 2004).

Chlorhexidine, a broad-spectrum antiseptic, has been used extensively in clinical settings to cleanse the umbilical cord and prevent infection in neonates. Evidence suggests that chlorhexidine interventions may have significant public health impact on the burden of neonatal infection and mortality in developing countries (Mullany, Darmstadt, and Tielsch, 2006).  Keeping the cord dry and avoiding the application of other substances to the cord are components of newborn clean cord care. Further details on cord care can be found in Save the children (2004); (Save the Children, 2010); and USAID/CORE Group(2004). This indicator measures one of several cord care practices that can improve infant health outcomes and is directly related to achieving Millennium Development Goal #4 to reduce infant and child mortality.

Surveys rely on recall of events and this indicator is subject to recall bias, which is likely to increase with the length of the recall period. Recall bias can be minimized by keeping the reference period short. A mother may not know if anything was applied to her most recent baby’s cord after delivery and there is also the possibility that a mother would report the recommended behavior rather than actual practice (Gage et al., 2005). Direct observation is a way to avoid this bias.

quality, newborn (NB)

Gage A, Ali D, Suzuki C, 2005, A Guide for Measuring and Evaluating Child Health Programs, Chapel Hill, NC: MEASURE Evaluation.  

Mullany L, Darmstadt G, and Tielsch J, 2006, "Safety and Impact of Chlorhexidine Antisepsis Interventions for Improving Neonatal Health in Developing Countries". Pediatric Infecttious Disease Journal, August 25(8): 665-675. 

Save the Children, 2010, Report of a Technical Working Group Meeting on Newborn Health Indicators, Washington, DC: Save the Children.

Save the Children, 2004, Every Newborn’s Health: Recommendations for care for All Newborns, Washington, DC: Save the Children.

USAID/CORE Group, 2004, Maternal and Newborn Standards and Indicators Compendium, Washington, DC: USAID

WHO, 2015, Integrated Management of Pregnancy, Childbirth, Post Partum, and Newborn Care: A Guide for Essential Care Practice, Geneva: WHO.

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