Abstract
Background:
Ethiopia continues to experience a high neonatal mortality rate (33 per 1000 live births), with neonatal sepsis being a major contributing factor. Chlorhexidine (CHX) gel is recommended for umbilical cord care in high-risk settings to prevent infection; however, its utilization remains low. Therefore, this study aimed to assess the magnitude of CHX gel utilization for newborn cord care and identify associated factors.
Methods:
A cross-sectional study was conducted among 415 mothers of infants under 6 months in Asella town. Data were collected using a structured questionnaire and analyzed with SPSS 26. Binary logistic regression identified factors linked to CHX use.
Results:
CHX utilization was 30.2% (95% CI: 25.5-34.9). Factors significantly associated with use being multiparous (AOR = 2.60), receiving cord care counseling (AOR = 2.09), having good knowledge (AOR = 2.08), and a positive attitude (AOR = 2.50).
Conclusion:
Only one-third of mothers used CHX appropriately. Strengthening maternal education, counseling, and community awareness is vital to enhance safe newborn cord care.
Introduction
The umbilical cord connects the fetus to the placenta from about the sixth week of pregnancy until birth. 1 After birth, the umbilical stump dries, shrinks, and detaches within 1 to 2 weeks, changing color from yellow-green to dark brown or black. Proper hygiene during this period is essential to prevent infection. 2 Improper cord care, such as unhygienic clamping, cutting, or the application of harmful substances, increases the risk of newborn infection and mortality. Neonates are particularly at risk of developing sepsis when microorganisms colonize the umbilical cord stump and enter the bloodstream, often leading to omphalitis. 3
Globally, approximately 2.5 million newborns die within the first month of life each year, accounting for about 47% of all under-5 deaths, with infections being the second leading cause. 4 Although substantial progress has been made since 1990, reductions in neonatal mortality remain slow, particularly in sub-Saharan Africa and South Asia, where rates are about 27 deaths per 1000 live births.5,6 Africa alone accounts for nearly four-fifths of the global neonatal death burden. Furthermore, in community, unhygienic newborn-care practices lead to continued high risk for omphalitis.7,8
In Ethiopia, the neonatal mortality rate is estimated at 33 per 1000 live births, placing the country among those with the highest rates of newborn deaths globally. 9 Nearly two-thirds of these deaths could be prevented through proven interventions implemented at birth and during the first week of life. 10 Neonatal sepsis (NNS) within the first 2 weeks of life remains a leading cause of neonatal mortality. 11 One study conducted in Enugu, Southeast Nigeria reported that sepsis and tetanus both major complications of umbilical infections together accounted for about 60% of all neonatal deaths, with sepsis responsible for 23.3% and tetanus for 13%. 12 Effective umbilical cord care practices are therefore critical to reducing NNS associated with stump infections. 13
The World Health Organization recommends the application of 7.1% chlorhexidine (CHX) digluconate gel to the umbilical cord stump once daily for 7 consecutive days in settings with high neonatal mortality, such as Ethiopia, where unhygienic delivery conditions and neonatal mortality rates exceeding 30 per 1000 live births pose significant risks to newborn survival. 11 Ethiopia has adopted this recommendation, promoting CHX application immediately after birth and daily until the stump falls off or for a maximum of 7 days. 13 However, limited studies have assessed the proper utilization of CHX gel in Ethiopia, and few have explored its associated factors in specific settings. Hence, this study was conducted to determine the magnitude of CHX gel utilization and identify associated factors among mothers attending public health facilities in Asella Town, Ethiopia
Methods and Materials
Study Design and Settings
An analytical cross-sectional study was conducted at public health facilities in Asella town, Ethiopia from 1 May 2025 to 30 July 2025 on all the mothers who had a live baby aged below 6 months and residing in Asella town. The town is located 175 km away from Addis Ababa in the Southeast Ethiopia. According to the Asella town health office report of 2023/24, the town has an estimated population size of 196 410. Out of the total population, about 2808 of the total population are expected to have children less than 6 months of age. 14
Inclusion and Exclusion Criteria
Mothers residing in Asella Town for at least 6 months with infants younger than 6 months were included. Mothers with stillbirths, deceased neonates, or infants younger than 1 week were excluded, as chlorhexidine (7.1% digluconate gel) is recommended for 7 consecutive days after birth. The gel was applied once daily following WHO guidelines. Premature or critically ill neonates unable to receive routine CHX care were effectively excluded. Mothers who used traditional substances alongside CHX were excluded from this assessment.
Sample Size Determination and Sampling Procedures
The sample size was calculated using the single population proportion formula based on the following assumptions: a proportion (P) of chlorhexidine utilization for the recommended 7 days or more in Ethiopia of 48.3% in 2022, 15 a margin of error (d) of 5%, and a 95% confidence level (Z α/2 = 1.96). Therefore, by considering 10% non- response rate, the final sample size was 423. During the sampling process, all 3 public health facilities in Asella town were included to obtain a representative sample. Participant numbers for each facility were determined based on the average monthly client flow from immunization and postpartum clinics, totaling 1155. The sampling frame consisted of postnatal and immunization service registers listing mothers with infants under 6 months of age. To avoid recruiting the same mother twice, only those not previously included were eligible. The total sample size was proportionally allocated to each facility, and participants were selected using systematic random sampling with a sampling interval of 3 (k = 3), starting from a randomly chosen point between 1 and 3, until the allocated sample size for each facility was reached.
Outcome Measures
The main outcome measures were the CHX use over a 7 days period by the mothers. Secondary outcomes were factors associated with CHX gel utilization.
Operational Definition
Data Collection Procedures, and Quality Assurance
Data were collected through face-to-face interviews, structured questionnaires developed after reviewing relevant literature. Content validity was ensured by expert review and pre-testing. covering all relevant domains of maternal and newborn care, including knowledge and attitude toward CHX cord care.12,13,16 Data were collected by 6 diploma-level clinical nurses who were carefully selected based on their prior experience in maternal and child health services and competency in data collection procedures. They were supervised by two M.Sc.-level midwives to ensure adherence to the study protocol, data quality, and ethical standards throughout the data collection process. To ensure data quality, the questionnaire was initially developed in English and translated into Afan Oromo and Amharic by language experts. It was pre-tested on 5% of the sample at Sagure Health Center, located 25 km from the study area, and modifications were made for sequence, grammar, and interview procedures. The tool’s reliability was assessed using Cronbach’s alpha (overall α = .904). Data collectors and supervisors received 1-day training from the principal investigator on the study objectives and data collection procedures. During data collection, supervisors and the principal investigator closely monitored the process daily to ensure completeness and consistency.
Data Processing and Analysis
Data was entered into EpiData 4.6 and exported to SPSS version 26 for analysis. Descriptive statistics were used to summarize frequencies and percentages of independent and dependent variables. Data were first checked for completeness and consistency before analysis. Mothers who reported applying traditional substances alongside CHX were excluded from the assessment of adequate CHX utilization to maintain a clear evaluation of adherence to recommended CHX-only cord care practices. The overall proportion of missing data was minimal and did not affect the representativeness of the final dataset. The selection of variables for the multivariable logistic regression model was based not only on the bivariate analysis (P < .25) but also on theoretical relevance and findings from previous literature. A conceptual framework guided the inclusion of key socio-demographic, maternal, and service-related factors that were hypothesized to influence CHX utilization for umbilical cord care. Multicollinearity among the independent variables was assessed using the variance inflation factor (VIF), with a maximum VIF of 1.263, indicating no significant multicollinearity. Statistical significance was declared at P < .05, and the strength of associations was expressed using adjusted odds ratios (AOR) with 95% confidence intervals. Model fitness was evaluated using the Hosmer–Lemeshow goodness-of-fit test (P = .465), indicating an adequate model fit
Ethical Approval and Informed Consent
The study received ethical approval from the Institutional Review Board (IRB) of Arsi University, College of Health Sciences (Ref. No. A/U/H/S/C/121/4219/17). Written informed consent was obtained from all adult participants after the purpose of the study had been clearly explained to them. For participants who were minors (aged <18 years), written assent was obtained from the mothers themselves, and additional consent was obtained from their parents or legal guardians prior to participation. Participants were informed that their participation was voluntary and that they could withdraw at any time or decline to answer any questions without any consequences. Confidentiality was maintained by using coded identifiers instead of personal information. All research procedures were conducted in accordance with the principles of the World Medical Association’s Declaration of Helsinki.
Results
Socio-Demographic Characteristics of Study Participants
Out of 423 calculated study participants a total of 415 mothers participated in the study making the response rate 98.1%. The mean age (±SD) of the respondents was 29.7 (±7.18) years. One hundred and forty-seven (35.4%) of the respondents were in the age group 25 to 34 years. Four hundred and four (97.3%) of participants were married. About 220 (53%) of study participants were Oromo by ethnicity. Among the total participants, 183 (43.9%) mothers attended secondary school and above while about 201 (48.4%) of study participants were housewives (Table 1).
Socio-Demo Graphic Characteristics of Mothers, Ethiopia, 2025.
Single, divorced & widowed.
Obstetrics Related Factors
Among the 415 mothers included in the study, the majority (84.3%) were multiparous. Most participants (90.4%) reported no previous history of neonatal death. Nearly all mothers (89.4%) received antenatal care (ANC) during their recent pregnancy, and among them, 81.1% attended 4 or more ANC visits. Regarding the place of delivery, 50.2% delivered at hospitals, 44.3% at health centers, and 5.5% at home. The majority (90.1%) delivered via spontaneous vaginal delivery. Postnatal care (PNC) service utilization was high, with 95.7% of mothers receiving PNC, and 70.4% were counseled on umbilical cord care (Table 2).
Obstetric and Maternal Health Related Characteristics, 2025.
Knowledge on Chlorhexidine
Out of the total 415 respondents, 248 (59.8%) of mothers demonstrated good knowledge, while 167 (40.2%) had poor knowledge regarding the use of chlorhexidine gel for umbilical cord care. The majority, 344 (82.9%), had heard about CHX gel, primarily from health professionals. Among them, 245 (59%) know how to apply chlorhexidine gel on their newborn’s umbilical cord stump. Furthermore, 242 (58.3%) of the participants correctly identified the purpose of chlorhexidine application mainly for preventing infection and promoting safe cord healing. Similarly, 235 (56.6%) of mothers knew how frequently chlorhexidine gel should be applied, in accordance with the recommended daily use until the cord stump falls off or up to 7 days (Figure 1).
Maternal knowledge of CHX gel utilization, Ethiopia, 2025.
Attitude Toward Chlorhexidine Gel Use
Attitude toward CHX cord care was assessed using eight Likert-scale items. While the primary analysis dichotomized responses into favorable and unfavorable, a secondary analysis could treat attitude as a continuous or ordinal variable to retain more information. Most mothers expressed positive attitudes regarding its importance (67%), safety (65.8%), infection prevention (62.7%), and hand washing before application (83.9%), but fewer agreed with recommending it to others (48.4%) or believing it has no side effects (44.3%). Overall, 59.2% had a positive attitude, and 40.8% had a negative attitude (Figure 2).
Maternal attitude toward CHX gel utilization, in Asella Town, Ethiopia, 2025.
Magnitude of Chlorhexidine Gel Utilization
The study revealed that 125 (30.2%) of mothers demonstrated adequate utilization of CHX gel for umbilical cord care with a 95% confidence interval (CI) of 25.5% to 34.9%, while 290 (69.8%) showed inadequate utilization. This indicates that less than one-third of the mothers practiced chlorhexidine application in accordance with recommended guidelines.
Factors Associated With Chlorhexidine Utilization
In the bivariable analysis, maternal age, educational, parity, history of neonatal death, place of delivery, receipt of counseling, knowledge, and attitude were identified as candidate variables for the multivariable logistic regression at a P-value <.25. In the multivariable analysis, parity, being counseled, positive attitude, and good knowledge remained significantly associated with CHX utilization at a P-value <.05. Mothers who were multiparous were 2.60 times more likely to utilize CHX compared to primiparous mothers (AOR = 2.60; 95% CI: 1.06-6.38). Mothers who received counseling on cord care were 2.09 times more likely to use chlorhexidine than those who did not (AOR = 2.09; 95% CI: 1.08-4.06). Likewise, mothers with a favorable attitude toward chlorhexidine use were 2.50 times more likely to utilize it compared to those with an unfavorable attitude (AOR = 2.50; 95% CI: 1.35-4.62). Furthermore, mothers with good knowledge about chlorhexidine were 2.08 times more likely to use it compared to those with poor knowledge (AOR = 2.08; 95% CI: 1.16-3.70; Table 3).
Factors Associated with CHX Gel Utilization for Umbilical Cord Care, Ethiopia, 2025.
Abbreviations: 1 = used as reference category; COR, crude odds ratio; AOR, adjusted odds ratio; CI, confidence interval.
Statistically significant at P < .05.
Discussion
This study found that only 30.2% of mothers reported adequate utilization of CHX gel for umbilical cord care. This indicates that the majority of mothers did not use CHX as recommended, which may reflect gaps in awareness, counseling, and attitudes toward its appropriate use during newborn cord care. The finding is comparable to a study conducted in another region of Ethiopia, where 34.4% of mothers demonstrated adequate CHX use. This similarity suggests that low utilization of CHX gel for umbilical cord care might be a widespread issue across different parts of the country, possibly linked to common systemic or behavioral factors such as limited health education, inconsistent supply, or cultural practices surrounding newborn care 15 However, it is lower than findings reported in Nigeria (46.6%) 12 and Nepal (50.7%). 17 The detected discrepancy may result from variations in the study durations, sample numbers, and study locations. Additionally, the disparities may be explained by variations in the characteristics of the study population, the study design, and the methods used for data collecting.
Regarding associated factors, mothers who were multiparous were more likely to utilize CHX gel compared to primiparous mothers. This could be attributed to the fact that multiparous mothers generally have more experience and awareness of newborn care practices due to their previous childbirth experiences. They are also more likely to have received health education or counseling during prior deliveries, which may enhance their understanding of the benefits of cord care using CHX gel. This finding is consistent with a study conducted in Tanzania. 18 which similarly reported higher utilization of CHX among mothers with multiple births compared to first-time mothers. The possible explanation could be that multiparous mothers have greater exposure to health education and counseling during previous pregnancies, which increases their awareness and understanding of CHX use. It could be due to their prior experiences with healthcare services that may make them more confident and comfortable using chlorhexidine.
In this study we found that mothers who received counseling on cord care were also more likely to utilize chlorhexidine gel compared to those who did not receive such counseling. This agrees with the recommendations of the WHO and United Nations International Children’s Emergency Fund (UNICEF).1,11
This may be due to the fact that counseling increases mothers’ awareness of the significance of chlorhexidine in preventing infections of the umbilical cord. Mothers’ motivation and confidence in adhering to medical instructions, such as the regular use of chlorhexidine for cord care, can also be boosted by appropriate counseling. Mothers are more likely to incorporate CHX into their newborn care routines if they are aware of its preventive advantages.
In the present study, overall, about 59.2% of mothers had a positive attitude toward chlorhexidine gel use, while 40.8% had a negative attitude. Furthermore, mothers with a positive attitude toward chlorhexidine use were more likely to utilize it compared to those with a negative attitude. This finding is in line with studies conducted in Nigeria. 19 This is justified as a positive attitude may reflect a belief in its necessity and efficacy in maintaining neonatal health, which may encourage consistent application of the gel during the postnatal period.
In the current study, the overall knowledge about CHX use was good among mothers. This is similar with a study conducted in Nigeria 12 which shows that mothers who had good knowledge about chlorhexidine gel use were more likely to utilize it than those who had poor knowledge. This result is supported by studies conducted in Nigeria and Ethiopia. 13 This could be due to knowledgeable mothers being more likely to make informed decisions about their newborn’s care and understand the benefits of using CHX. Women’s awareness of its role in preventing infections and promoting newborn health likely enhances adherence to recommended cord care practices.
Limitations of the Study
This study has several limitations that should be considered when interpreting the findings. First, the cross-sectional design limits the ability to establish causal relationships between associated and CHX utilization. Second, adequate utilization was assessed based on self-reports up to 6 months postpartum this data may be affected by recall or social desirability bias, potentially leading to over or underestimation of actual practices. Third, the study was facility-based, recruiting mothers who attended immunization or postpartum services. These mothers are likely to have higher exposure to health services, including antenatal and postnatal counseling and facility-based delivery, which may not reflect the practices of mothers who do not access such services. Consequently, there is a risk of selection bias, and the findings may not be generalizable to the broader community, particularly non-attenders who may have the lowest CHX uptake.
Conclusions
This study found that only about one-third (30.2%) of postpartum mothers utilized CHX gel appropriately for umbilical cord care. Utilization was significantly higher among mothers who were multiparous, received counseling on cord care, had good knowledge, and demonstrated a positive attitude toward CHX use. These findings suggest that both maternal awareness and the quality of counseling services play a crucial role in promoting the proper use of CHX for newborn cord care. Therefore, strengthening health education and counseling during antenatal care, delivery, and postnatal follow-up is essential to improve mothers’ CHX utilization. In addition, community-level awareness campaigns and integration of CHX messages into routine maternal and child health programs could help increase its adoption.
Footnotes
Acknowledgements
The researchers would like to thank the midwifery department of Arsi University and Asella health officers for supporting for this study.
Abbreviations
Ethical Considerations
The study was approved by the Institutional Review Board (IRB) of Arsi University, College of Health Sciences (Ref. No. A/U/H/S/C/121/4219/17).
Consent to Participate
The informed consent with a written signature was obtained upon the agreement from participants after purpose of study had been explained. There were informed to withdraw at any time and/ or to refrain from responding to questions. Study participants were also informed that all the data obtained from them could be kept confidential using code instead of any personal identifiers. Furthermore, the research procedures were conducted in accordance with the principle expressed in The World Medical Association’s Declaration of Helsinki.
Author Contributions
N.F., H.A. and D.B.W were involved in the design and data collection of the study. D.B.W was involved in drafting the manuscript. N.F., H.A. and D.B.W undertook proofreading and final editing and formatting. N.F did the statistical analysis. All authors have read and agreed to the published version of the manuscript.
Funding
The authors received no financial support for the research, authorship, and/or publication of this article.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Data Availability Statement
All data of this study are available from the corresponding author upon reasonable request.*