Local Perceptions, Traditional Cultural and Religious Beliefs and Practices on Umbilical Cord Care in Tharu Community of Nepal: A cross sectional study

Abstract

Globally, neonatal sepsis accounts for 15% of neonatal death, and nearly half (48%) of neonatal deaths in Nepal. Interventions such as Chlorhexidine (CHX) gel for umbilical cord care have been widely implemented in Nepal after randomized clinical trials (RCT) demonstrated efficacy and safety to reduce infections of the umbilical cord, omphalitis, and sequelae of unresolved infections which include sepsis. However, local traditional cultural or religious beliefs and practices can reduce or eliminate the efficacy of modern cord care which results in a high prevalence of omphalitis. Successful implementation of the CHX intervention, therefore, requires increased knowledge of the local practices which involve the umbilicus, at and shortly after birth, to identify augmentation strategies to the implementation of CHX. This study was carried out in the western rural Terai region in Nepal and compared three groups: the Tharu omphalitis-positive cases, the non-Tharu omphalitis-positive cases, and the Tharu omphalitis-negative cases. In total, 59 structured and semi-structured interviews with recently delivered women (RDW) (in the last seven months) and 17 health facility surveys with delivery and child care providers were conducted.Facility delivery was common among the study population, yet seeking health care service from non-facility sources was high in omphalitis-positive cases. Subjects reported application of traditional substances (i.e. mustard oil and ginger powder) was common in the community and that substances application had three main purposes: 1) application of mustard oil was common amongst all groups for “preventative” (maintain good health) purposes; 2) after infection of umbilical cord, substances were applied for “treatment” purpose in some omphalitis-positive cases; and 3) application to hasten cord separation after cord separation was perceived to be delayed was also reported in some omphalitis-positive cases. Almost all women from the Tharu omphalitis-positive cases reported a “naming ceremony”, giving the child its given names in a religious/culture ceremony with family and friends, should follow the cultural tradition to be held after cord separation, which is reported amongst few women from the Tharu omphalitis-negative cases and half of women from the non- Tharu cases. Holding the naming ceremony before the 12th day after birth was reported as very common amongst the non-Tharu cases. Among all the sub-groups studied, women reported having a limited power to make health-related decisions, as compared to their mother-in-law, father-in-law, and husband who the respondents described as having more power.This study concludes that traditional cultural/religious beliefs and practices play an important role, particularly as they relate to cord care, in the western rural Terai region of Nepal. The introduction of CHX intervention do not replace but integrate into the existing traditional practices. In the discussion, an interaction is observed where CHX gel formulation, onset of omphalitis, and traditional cord care practices may delay cord separation which postpones the naming ceremony for tradition-observing the Tharu peoples. It would be useful as a follow up study to compare dry and gel formulations of CHX, in single and multi-dose regimens, in conditions where traditional cord care practices are used and not used. This would provide even greater insight into how best to proceed to reduce omphalitis and its complications. The current study is underpowered to make conclusive observations, but it is clear that in spite of CHX single dose being applied in the clinic at birth, infections are occurring at higher rates among those peoples who use traditional cord care practices. Subjects in this study report they have been counseled on the use of CHX and the desirability of not using any other agents on the cord stump, but they continue to do so in the belief it may prevent infection, may treat infection and may accelerate cord separation. Given that cord separation is linked to a socially significant cultural admission of the child into the community, the “naming ceremony”, it is not surprising that traditional practices continue given the high social valence of the ceremony. This study also provide implication for policy and practice that a redesign of community campaign to destigmatize delayed naming ceremony and empower women in making healthcare decisions. This study suggests that the efficacy of CHX to reduce infections may be reduced in the natural setting where traditional cord care continues after CHX is applied in a single dose administration. Determining the best formulation and dosing of CHX that can be effective in conjunction with traditional cord care practices is needed to reduce infections among the Tharu and other traditional peoples who use cord care practices. This is particularly needed where cord separation is linked to a cultural significant event such as the “naming ceremony” and the likelihood of completely extinguishing traditional cord care practices is low.