Introduction
The health workforce is one of the key components of a well-functioning health system besides good leadership and governance, sound financing strategies, availability of essential medical supplies, innovative service delivery approaches, and proper health management information systems [
1]. The ability of the health workforce to adequately respond to the needs of consumers of health services is, in turn, dependent on staffing levels, training, distribution, motivation, and retention [
1‐
3]. However, the performance of adequate, well-trained, evenly distributed, and highly motivated health workforce may still be affected by other health systems factors such as leadership, governance, and supplies [
2,
3]. Developing countries particularly face challenges with respect to ensuring efficiency in all the elements of a well-functioning health system [
4,
5]. The challenges may be exacerbated in contexts of rapid changes in governance, financing, medical technologies and products, service delivery approaches, and information technology which may exert greater strain on the existing health systems of developing countries.
Guidance on appropriate newborn umbilical cord care is one area that has witnessed changes over time, which health systems of developing countries could experience challenges adjusting to. Evidence shows that there have been inconsistent practices using a variety of cleansing agents and techniques over time including alcohol-based solutions or antiseptics, antimicrobial treatment, and natural healing or dry umbilical cord care [
6‐
8]. In addition, due to socio-economic and socio-cultural circumstances, different communities in low-resource settings apply unhygienic substances to the cord thereby increasing the chances of neonatal infections and mortality [
9‐
12]. As a result, developing countries continue to bear the greatest burden of neonatal morbidity and mortality [
13,
14]. Based on results from randomized clinical trials that showed that using 7.1% Chlorhexidine Digluconate (CHX) that releases 4% chlorhexidine for umbilical cord care significantly reduces neonatal morbidity and mortality in regions with high prevalence [
15‐
19], the World Health Organization (WHO) included it in the essential medicines list for umbilical cord care in neonates in 2013 for use in settings with neonatal mortality rates of 30 deaths per 1000 live births or higher but also in regions with low neonatal mortality where the application of harmful traditional substances such as cow dung to the cord stump exist [
20].
CHX is registered for topical use in Kenya but it is still not widely available. In order to generate evidence to inform the national roll-out of the medication, Save the Children began implementing a program in Bungoma County in western region of Kenya in early 2016 that involved availing 7.1% CHX in gel formulation to mothers through a controlled managed access program (MAP). The program was funded by GlaxoSmithKline (GSK) and implemented by Save the Children in collaboration with the Ministry of Health and the County Department of Health in 21 purposively identified public hospitals, health centers and dispensaries in Bungoma County while the evaluation was conducted by the Population Council. The introduction of the medication through health facilities was informed by a number of factors. First, since its use requires observance of some hygienic practices such as handwashing before application, the health facility was the first logical entry point where such hygiene could be observed and mothers could be educated on how to observe the same at home. Second, it was a more cost-effective way of reaching several mothers at the same time with information on the hygienic practices and application procedures as opposed to visiting each mother at home. This was later evident from interviews with mothers who used Chlorhexidine that showed that the approach was very effective in helping them understand how to apply it at home, including observing handwashing before and after application. Third, in such a rural community, most mothers trust information given by trained health care providers than anybody else. It was therefore anticipated that facility introduction would increase chances of correct use of the medication if the information came from trained health care providers.
This paper explores the perspectives of service providers regarding the use of CHX gel for newborn umbilical cord care under the program. Understanding the perspectives of service providers is, in turn, important for informing strategies for scaling up the use of the medication. This is critical given the key role the health workforce plays in the health system and the fact that their views could be influenced by prior beliefs and inconsistent practices regarding umbilical cord care. In addition, although there are no published studies that examined health care workers attitudes towards the use of Chlorhexidine for umbilical cord care, available evidence shows that the environment in which an intervention is introduced—including health systems and community context—may influence the acceptability of certain newborn care practices such as delayed bathing and dry cord care among mothers and health care workers, especially in rural settings of developing countries, thereby requiring negotiations for alternative practices [
12,
21].
Context
Until 2013, the national guidelines for Kenya recommended dry cord care but there is evidence that health care providers use alcohol-based solutions, methylated spirit or iodine to clean the cord [
9]. In addition, given that a substantial proportion (38%) of births in the country occur at home or outside of health facilities [
22], it is likely that many mothers use unhygienic substances for cord care. The proportion of births in Bungoma County that is delivered outside of health facilities (59%) is higher than the national average [
22], suggesting that most infants in the county are exposed to unhygienic cord care practices. Available evidence shows that the infant mortality rate in the county is 65 deaths per 1000 live births compared with the national average of 39 deaths per 1000 live births while the neonatal mortality rate is 24 deaths per 1000 live births compared with the national average of 22 deaths per 1000 live births [
22,
23]. In addition, the county has the highest fertility rate (of five children per woman) and the lowest proportion of births occurring in health facilities (41%) among the four counties (Bungoma, Busia, Kakamega and Vihiga) in western region of Kenya [
22]. Experience working in the study setting further showed that practices involving application of harmful traditional substances to the cord stump exist, which justifies the use of Chlorhexidine for cord care despite the neonatal mortality rate being below the threshold recommended by WHO. In particular, interviews with mothers who used Chlorhexidine showed that the application of traditional substances such as cow dung, traditional herbs, soil, soot, feces of lizard, feces of bat and chicken droppings to the cord stump still exist in the community.
It is against the backdrop of poor maternal, newborn and child health indicators that the CHX MAP was implemented in the county. Implementation of the program began in February 2016 and involved training of health care providers from the participating facilities on dispensing the medication and reporting adverse events; developing and disseminating information, education and communication (IEC) materials on CHX; and supplying the medication to the facilities. Although the program was facility-based, community midwives, community health extension workers (CHEWs), community health volunteers (CHVs), and birth companions (former traditional birth attendants attached to facilities to accompany mothers for health services) from the county were sensitized about the medication so that they could disseminate the information in the community and encourage mothers who gave birth at home to visit the facilities for CHX. Each mother was provided with a packet of CHX that contained seven sachets. The first application was done by the provider at the facility as per the guidelines and mothers were shown how to apply the rest at home. Mothers were then instructed to use one sachet once a day for the remaining six days and discard whatever remained in the toilet. However, CHX was applied only once at the facility for low birthweight babies (less than two kilograms). This was a policy decision made during the design of the intervention based on reports of increased risk of CHX irritation in low birthweight or pre-term babies and the fact that the most efficacious dose of CHX is the first dose given at or as close to the time of cutting of the cord as possible. However, for mothers who gave birth at home and were referred to health facilities for CHX by CHVs and birth companions, the efficacy of the medication might have been reduced due to delayed initiation of the first dose.