Study design

The study adopted an exploratory qualitative design using key informant interviews (KIIs) guided by semi-structured question guides, and which were conducted between 6^th October 2022–9^th November 2022. The data was collected from six health facilities in Kiambu County.

Study setting

This study was carried out in Kiambu County, Kenya, which has a population of over 2.4 million people. The location coordinates are 1⁰ 10’S 36⁰50’E, and it neighbors six other counties, namely Nairobi City and Kajiado Counties to the South, Machakos to the East, Murang’a to the North East, Nyandarua to the North west, and Nakuru County to the West [19]. The county is 60% urban and 40% rural due to its proximity to the capital city Nairobi.

The county has 505 health facilities, comprising 108 public, 64 faith-based, and 333 privately owned facilities. In Kenya’s health system, Level 1 refers to community-based services (e.g., health promotion and preventive care), Level 2 to dispensaries, Level 3 to health centers, Level 4 to sub-county hospitals, and Level 5 to county referral hospitals.

Maternity services are typically offered at Level 3 (health centers) and above, including private and faith-based hospitals. Therefore, this study gathered insights from HCWs working in Level 3, 4, and 5 public facilities, as well as private hospitals. One of the Level 5 hospitals (Thika Level 5 Hospital) in this study also functions as a teaching hospital for medical and nursing students.

Local context

CHX for newborn umbilical cord care is available in two formulations: gel and solution [20]. Both forms are recommended by the WHO and are included in the Kenya Essential Medicines List as well as in postnatal care guidelines [20–22]. In line with this, Kenya’s Ministry of Health (MoH) endorses the availability and use of both CHX formulations [20].

The choice between the dosage formulations used depends on what is acceptable to mothers, caregivers, HCWs and availability [23].

According to the national guidelines, immediately post-delivery, a HCW should apply CHX to the newborn’s umbilical cord using sterile gloves. The antiseptic is applied to the base, stump, and tip of the cord [20]. For gel formulations, the HCW uses their index finger to spread it; for the solution, the dropper is used to apply CHX directly. The CHX is not cleaned off after application. In the postnatal period, CHX should be applied once daily until the seventh day or until the cord naturally detaches: whichever happens first. Mothers and/or caregivers are instructed on how to apply CHX at home following the same procedures, but in lieu of sterile gloves, they are advised to thoroughly wash their hands before each application.

The National Health Insurance Fund (NHIF), now defunct, but which was active during the period of the study, had a program called Linda Mama that covered the costs of antenatal care (ANC), delivery, and postnatal care (PNC) for all pregnant women [24]. However, it notably excluded the cost of CHX, and currently, there is no government-sponsored program providing CHX free of charge to mothers during the postnatal period.

Study population and sampling

The study population consisted of over 2,600 HCWs providing health services in Kiambu County during the study period. No formal sample size was calculated and we applied the information saturation principle [25]. Two providers were targeted in every unit (with a target of 30 HCWs) during the study’s formulation, however some units were understaffed during the study and hence only had one HCW interviewed. The cadre and respective facility of the sample are presented in Table 1.

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Table 1. Facility sampled and cadre of the healthcare workers interviewed who are involved in the continuum of cord care.

https://doi.org/10.1371/journal.pone.0326506.t001

Inclusion criteria - HCWs who had direct interactions with neonates or were involved in providing or handling CHX cord antiseptic during the study period, and who had at least 6 months of experience with cord care.

Exclusion criteria - HCWs who were not directly involved in newborn care or who declined to provide informed consent and who had less than 6 months of experience with cord care.

Data collection

A total of 38 KIIs were conducted between 6th October 2022 and 9th November 2022.

All interviews were conducted by two members of the study team, JMG and BNO, both holding Bachelor of Pharmacy (BPharm) degrees. JMG serves as the Kiambu county pharmacist and holds a PhD in pharmacy, while BNO is a researcher with experience in qualitative data analysis. Both researchers received training prior to data collection to ensure consistency and quality.

The interviews were conducted in English, but participants were allowed to respond in either English or Kiswahili. BNO, who is bilingual and fluent in both written and spoken English and Standard Kiswahili, translated the KIIs, which were audio-recorded and transcribed verbatim directly from Kiswahili into English when applicable.

Each participant was assigned a unique index number (1–38), and quotations are referenced using the format: HospitalName_Cadre_IndexNumber.

Data management

Kobo Toolbox software was used to collect and manage data, with all data coded to conceal the participants’ identities. To ensure data security, electronic data collected via KoboCollect were encrypted and password-protected on the devices. After transfer, data files were securely stored on password-protected computers and backed up on a secure cloud platform with restricted access. NVivo project files were similarly protected to maintain confidentiality and data integrity throughout the analysis process.

Data analysis

Interview transcripts were imported into NVivo software to assist in the classification, sorting, and coding of data into central themes and subthemes. The coding process followed a two-cycle approach. In the first cycle, value coding was used to capture participants’ attitudes and values, reflecting their perceptions and experiences. The second cycle involved focused and pattern coding. Focused coding developed specific categories without focusing on their properties, while pattern coding grouped similar codes into meaningful units for theme identification [26–28].

NVivo’s platform played a crucial role in facilitating this multi-level coding process, ensuring consistency in the analysis framework by identifying recurring patterns and connections. The research questions and interview guide informed the coding frame, allowing for accurate classification of notable data segments to reveal dominant themes. The integration of value, focused, and pattern coding in both cycles ensured a comprehensive and structured analysis of the interview data [26–28].BNO, JMG, and PKJ also independently reviewed the transcripts to familiarize themselves with the data and identify initial codes. Discrepancies were resolved through discussion to ensure consistency and reliability.

Ethical considerations and approvals

Upon arrival at the various study sites, verbal consent was initially sought from the manager of each facility unit, followed by written consent from the hospital medical superintendent.

Prior to the initiation of data collection, participants were informed about the study’s objectives and their role as respondents. They were assured that participation was entirely voluntary and that they had the right to withdraw at any time. All data collected by the researchers were treated as confidential and utilized exclusively for this study. Access to the materials was restricted to the investigators, and stringent data management protocols were implemented to uphold the confidentiality of the study subjects.

Approval was obtained at various administrative levels, including county and sub-county authorities before the study commenced. Ethical clearance was secured from the University of Nairobi/Kenyatta National Hospital Ethical Review Committee [P470/05/2022], County Government of Kiambu Department of Health Services, Kiambu County [KIAMBU/HRDU/22/09/14/RA_GITHINJI], and a research license was obtained from the National Commission for Science, Technology and Innovation [NACOSTI/P/22/20446].

Demographic characteristics of participants

A total of 38 HCWs were interviewed, as depicted in Table 1. The mean age of respondents was 35.6 years (Range: 23–57 years). The HCWs interviewed had a mean of 9.4 years of professional experience, with a median of 7.5 years, a mode of 7 years, and a range spanning from 0.5 to 30 years. In terms of time spent at their current stations, the average was 4.4 years, with a median of 3 years, a mode of 1 year, and a range from the minimum of 0.5 years to 22 years. Participants had an average practice duration of 9 years.

Findings

The transcripts drawn from recordings of KIIs held with selected HCWs were analyzed, and themes emerged as 33 files with 52 references. Some themes mirrored the guiding questions in the semi-structured questionnaire, as shown in the coding tree as Fig 1.

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Fig 1. The coding tree of transcripts from interview audio recordings.

The numbers in brackets indicates the total number of individual references that mention that specific code within the files.

https://doi.org/10.1371/journal.pone.0326506.g001

A. Cord care practices in Kiambu county

1. National policy recommendation

We sought to understand the general cord care practices in various health facilities across Kiambu County by interviewing HCWs. According to MoH guidelines, the use of CHX for cord care has been officially recommended, with the directive being disseminated from the central government to the county level. This was confirmed by a participant from Nazareth Hospital, who stated, “first of all, we have the policy that is an order that came from Kiambu County from the Ministry of Health that chlorhexidine should be used” (Nazareth_Pharmacist_25).

The majority of participants acknowledged the existence of the MoH guidelines recommending CHX for cord care, confirmed that this policy had been communicated to health facilities and gave a description of the same policy in their responses.

“So after birth, when you cut the cord, immediately we use the chlorhexidine, and after, we use it once a day, once a day after delivery until now the mothers goes home and you instruct them to use it until the cord dries off and falls off.” (Nazareth_Midwife_27)

“…the next thing is to maintain hygiene of the cord, and this is done by applying an antiseptic. Commonly we use chlorhexidine, either the gel or the solution.” (Kiambu_ Paediatrician_36)

“...The guys from the [MoH] when they come, they say, “No, you must use [CHX]. You must use [CHX]...” (Thika_Midwife_13)

2. Facility-level departures from national recommendations

HCWs mentioned that surgical spirit remained the predominant choice in practice, indicating a reluctance to fully transition from previous guidelines. In fact, almost half (41.7%) of participants reported having prior experience with surgical spirit before being required to switch to CHX, which was a new product in their facilities. Some facilities reported not using CHX at all, relying solely on surgical spirit for cord care. This variation in practice highlights the need for further investigation into the slow adoption of CHX in these settings, despite the existence of formal guidelines.

Furthermore, despite clear directives, Thika Level 5 Hospital actively deviated from the National Guidelines, opting instead to follow its own facility-based protocol of dry cord care.

“Here in our health facility... We discussed with our pediatrician and we just decided to leave the cord just like that. Don’t put anything, don’t put water, don’t put the spirit, and don’t put chlorhexidine, as long as you keep it clean. And we have not had any case of sepsis... The guys from the [MoH] when they come, they say, “No, you must use [CHX]. You must use [CHX].” But then we are agreed for us, we don’t use it here, we have not been using it, and we have not had any cases of neonatal sepsis.” (Thika_Midwife_13)

“So the current cord care practice in Thika Level 5 I would say, predominantly because that’s where I practice is dry cord care. I hardly do surgical spirit or chlorhexidine or any other medication directly with the cord.” (Thika_ Paediatrician_12)

“And what I’ve noted, there is less uptake of chlorhexidine use for cord care compared to the surgical spirit.... the pediatrician and also other practitioners [are] persistent on the use of surgical spirit as opposed to chlorhexidine.” (Nazareth_ANC-nurse_23)

“So currently, in Kiambu County, there are different things that are being done … some places and institutions that are using chlorhexidine for cord care. Then a number of institutions are using surgical spirit. There are some people who even believe on doing nothing to cord care. There are people who are using normal saline for cord care.” (Thika_ Paediatrician_37)

“…I just know most of the time, they don’t even use that chlorhexidine. They use surgical spirit.” (Kihara_Pharmacist_18)

3. Mothers’ use of blended and traditional cord care methods

A minor theme emerged in which some HCWs reported that mothers used multiple cord care methods, often influenced by either their past experiences or family advice, or both. For example, if surgical spirit had been ineffective with their first baby, they would switch to CHX for subsequent children, and vice versa. In some cases, mothers who delivered during the era of previous guidelines recommending surgical spirit continued to favour it. Other practices included the use of saliva, a traditional method still common in our context.

“There is the use of … saliva, especially for the traditional mothers” (Ruiru_PNC-nurse_5)

“One challenge is that mothers out there, they have other methods of doing cord care. When you teach them how to do it, they go at home and they’re taught by other relatives how to do it … Like they will buy spirit because the other baby they used spirit, or they will use another thing like savlon that’s hindering proper use of the chlorhexidine.” (Nazareth_ANC-nurse_23)

“some mothers are resistant to change, especially those who delivered much earlier and chlorhexidine was not there before. So if they used spirit, they still want to use spirit … or even using saliva or cow dung.” (Nazareth_Midwife_27)

“The common challenge that we face is that mothers believe in the use of some traditional methods like use of saliva.” (Ruiru_Midwife_6)

B. HCW satisfaction with CHX for cord care

The preferences that HCWs had for CHX in cord care were varied, largely shaped by their clinical and anecdotal experiences with different methods. Approximately half of the HCWs who expressed satisfaction with CHX did so primarily due to its perceived effectiveness in preventing omphalitis and NNS. This ultimately reduced the need for additional healthcare visits for both mothers and newborns.

Many HCWs in favor of CHX also highlighted that it promoted quicker stump healing compared to other methods, provided that mothers followed proper instructions, maintained good hygiene, and began cord care immediately or shortly after birth. Additionally, CHX was praised for being easy to use, contributing to its widespread adoption and positive outcomes.

“So far, the outcomes have been good. We have had limited cases of sepsis after the use of chlorhexidine.” (Kiambu_Midwife_22)

“… those who practice, okay, cord care with chlorhexidine as they are instructed, the outcome is good.” (Kihara_Midwife_16)

“The use of chlorhexidine for cord care has made work easier in Kiambu since it’s easy to use and its availability, its efficacy being high has made it easier for us to manage the newborns and their mothers are even happy with the healing process using chlorhexidine gel.” (Kiambu_Pharmacist_34)

“The effectiveness of cord care is better compared with [traditional or surgical spirit] methods … in comparison with the mothers that have been using the surgical spirit and the cord care, during the postnatal checkup one week post-delivery, the mothers who have been using the chlorhexidine, the cords are healed faster compared with other methods.” (Ruiru_PNC-nurse_5)

C. Barriers to CHX adoption and effective use for cord care

1. Systemic barriers

One of the most significant barriers to the adoption and provision of CHX for cord care was its inconsistent availability in government health facilities. This challenge of access was twofold: not only was there a shortage of government-supplied CHX to health facilities, and when it was available, its cost often priced consumers out of the market. Many mothers at the facility found the cost of CHX prohibitive. As a result, HCWs recommended more affordable alternatives, which hindered CHX’s widespread adoption and led mothers to choose cheaper options like surgical spirit.

“…And then the erratic supplies for the county, particularly because of those financial constraints the counties have been having have made it easy for us to try out other things because in the absence of chlorhexidine, what else was being done to allow cords to heal... the supplies and the county, it’s quite irregular. The stock-outs are very, very, very common because of the budgetary constraints in the county.” (Thika_ Paediatrician _12)

“The first challenge is limited resources from the county. That is, when receiving our delivery from KEMSA, we might also be able to receive chlorhexidine. Another challenge is from the patients. Once the drug is prescribed, some patients may not be able to purchase from the pharmacies outside.” (Kihara_Pharmacist_24)

“The challenges of provision of chlorhexidine gel, first of all, I’d say it’s not readily available. As in, even if I sent a mother outside here to buy, I don’t think it’s as available as there rest. Secondly, the cost. It’s a challenge because the mothers are not able to afford it” (Githunguri_ANC-nurse_33)

2. Perceived product-specific disadvantages

Some HCWs associated CHX use with delayed cord healing, sepsis, and prolonged cord detachment. In a few instances, they reported that neonates had returned to the hospital with infections after its use. Concerns also emerged over the varying CHX formulations, which caused confusion, particularly due to its resemblance to tetracycline eye ointment and challenges in proper application. The drop formulation was especially scrutinized, with some HCWs believing it contributed to sepsis and soft tissue burns. Their perceptions of CHX's effectiveness were largely shaped by mothers’ feedback. These second-hand accounts reinforced the belief that CHX was less effective than other cord care methods, ultimately influencing its use within health facilities.

“…The [CHX] drops, the mothers are coming back with septic cords. I don’t know whether it’s the hygiene at home or what. I don’t get. But when we get a mother that comes and then we take the history, they say they bought the drops. But with the gel, no, not much sepsis. But with the drops, there is.” (Kiambu_Midwife_35)

“Now, the problem with the gel was that either it was too thick and it kept leaving the cord moist, and so it would take longer for the cord to drop off … So, a lot of children would come with delayed cord dropping.” (Thika_Paediatrician_12)

“Initially, we used to use the chlorhexidine gel, which was a bit difficult to use because it required one to wash their hands or change their gloves, apply the gel on their finger, and then spread the gel on the cord and surrounding skin. The gel could also be confused with tetracycline eye ointment because of the kind of packaging it came in. However, with the solution, it's much easier to use because all one needs to do is to drop a few drops on the umbilical cord and leave the baby's cord to dry. The packaging is also very different from the tetracycline eye ointment, so confusion is reduced.” (Kiambu_Paediatrician_36)

3.  Inconsistent use instructions

The data corpus revealed a significant knowledge gap among HCWs and mothers regarding the use of CHX for cord care, with some indicating that it should be applied once a day but others recommending it twice a day. HCWs often demonstrated preferences for alternative practices, reflecting a reluctance towards the adoption of CHX. These gaps were primarily due to insufficient HCW training on CHX application, leading to a lack of awareness among mothers about proper usage.

“… the mothers need an education. There are mothers who will not want to use chlorhexidine gel because of mythical thoughts or superstition, or that’s not what they were taught by their mothers to use. So, sensitization is needed … we need to sensitize the healthcare workers because sometimes we have found mothers who have not used chlorhexidine gel because the physician who was working with the mother did not believe in the working of chlorhexidine gel.” (Kiambu_Pharmacist_34)

4. Inertia

Among HCWs, the knowledge gap regarding CHX use is further complicated by resistance to switch from surgical spirit, which many have successfully used in the past. This resistance is often rooted in personal experiences with both products. HCWs tend to favor surgical spirit, largely due to their familiarity with it and the perceived shortcomings of CHX.

“I think the fact that most of the healthcare workers were used to surgical spirit, the switch to chlorhexidine and the fact that it takes time, the cord takes time to heal, I think most people are still reluctant to start mothers on the gel. They’ll prefer surgical spirit.” (Kihara_PNC-nurse_15)

D. Recommendations to increase CHX uptake

HCWs underscored the need for increased awareness and education among both HCWs and patients, citing persistent knowledge gaps regarding CHX’s benefits and proper usage. Many recommended improving accessibility by including CHX in maternity packages or ensuring its consistent availability in hospital pharmacies, thereby enabling timely application immediately after delivery, which is a critical factor for its efficacy.

Affordability also emerged as a central concern, with suggestions to reduce the cost of CHX and incorporate it into health insurance schemes such as (formerly) Linda Mama to alleviate the financial burden on mothers. Furthermore, HCWs advocated for comprehensive training programs targeting midwives, doctors, and pediatricians to deepen their understanding of CHX. Such training would enable healthcare providers to more effectively counsel patients, thereby promoting greater uptake of CHX in cord care practices.

“Yes. So number one, it’s the cost. It is readily available to them considering that it is covered by NHIF, number one...” (Nazareth_Midwife_27)

“Suggest that the hospital should source for more of the drug to ensure that it’s constantly available for use to increase its uptake.

Interviewer: If it was available, do you think everybody would use.

Interviewee: Yeah.” (Kiambu_Midwife_22)

“I think we need proper training for the staff, especially in maternity, even for us working in the postnatal clinics, because I understand the gel should be started immediately after birth.” (Kihara_PNC-nurse_15)

“The other one is educating, first of all, the healthcare worker on how to use it so that the healthcare worker is empowered to also educate the mothers on how to use it.” (Thika_Pharmacist_11)

E. Opinions on information, education, and communication (IEC) materials

IEC materials depicting the application of CHX were found to be largely unavailable and inadequate in healthcare facilities. A significant majority of respondents (86.1%) reported that these materials were inaccessible in most hospital units, resulting in ineffective promotion of CHX utilization. In cases where materials did exist, they were often not suitable for illiterate women, who frequently resorted to traditional methods of cord care.

To address this gap, HCWs suggested developing more inclusive IEC materials, such as pictorials and patient-friendly infographics, to ensure that all mothers could benefit from the health education provided. These materials included charts, pictograms, and illustrations that use inclusive language. using accessible language. These patient-friendly IEC materials should be strategically placed in locations such as antenatal clinics and labor wards, so that mothers are informed about the importance of CHX and can prepare to obtain it before delivery. HCWs also recommended tailoring resources specifically for their needs, including physical charts as reminders at workstations, along with Continuous Medical Education (CME) sessions and training programs. Observations made by the participants included the following:

“But in the facility in Githunguri, I’ve not seen any [IECs]. And I think CME is about the chlorhexidine would really help in creating awareness… everywhere, in every ward, in the postnatal rooms, and in labor ward, and also here in antenatal.” (Githunguri_PNC-nurse_29)

“On the issue of IEC materials, they’re not available in our facility. If they can be effective and brought down to the facilities, I would recommend they be more pictorial. By a glance, someone is able to know what it is and how it can be used and the readings big enough to be legible.” (Githunguri_ANC-nurse_33)

“The IEC material would help the staff here be at least more conversant for those who are not conversant with chlorhexidine gel, its use, its application, the period which the patient is supposed to use... Through the information the staff acquire, they’ll be able to make more informed decisions of even escalating the matter to facilitate the increase of the supply of the chlorhexidine gel in the facility and also acts a refresher …as opposed to other previous methods that were used of cord care…The IECs are not available at the facility at the moment...” (Kiambu_Midwife_22)

“For the charts, they should be bigger, and they should provide more charts so that we can put maybe in the wards and to educate the mothers. And for those mothers who are illiterate who cannot read, the wordings are many than the pictures. The pictures are better illustrating of how to use the chlorhexidine.” (Nazareth_Midwife_27)