A Systematic Review of the Effectiveness of Existing Umbilical Cord Care Interventions in Preventing Omphalitis and Reducing Neonatal Mortality in Sub-saharan Africa

A Systematic Review of the Effectiveness of Existing Umbilical Cord Care Interventions in Preventing Omphalitis and Reducing Neonatal Mortality in Sub-saharan Africa | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article A Systematic Review of the Effectiveness of Existing Umbilical Cord Care Interventions in Preventing Omphalitis and Reducing Neonatal Mortality in Sub-saharan Africa Precious Ebube Anyakorah, David Chinaecherem Innocent, Chidinma Peace Ahunam, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4400991/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 8 You are reading this latest preprint version Abstract Background Neonatal mortality remains a major public health concern in Sub-Saharan Africa, with umbilical cord infections accounting for a substantial proportion of these deaths. This systematic review seeks to synthesise existing evidence on the effectiveness of existing umbilical cord care strategies in preventing omphalitis and lowering infant mortality Sub-Saharan Africa using a narrative approach. Methods 1309 studies were identified through a thorough search of electronic databases such as PubMed, European PMC, and Google Scholar between 2014 and 2024. Studies were screened according to predetermined inclusion and exclusion criteria. Data was extracted using Microsoft Excel, In addition, the quality of the selected studies was assessed using the CASP checklist. Due to the heterogeneity of the selected studies the synthesis of data synthesis was performed using narrative synthesis Results The review includes six papers, including randomised controlled trials, observational research, and qualitative investigations. The included trials covered a wide range of therapies, such as chlorhexidine application, dry cord care, alcohol application, and clean birth kits. The combined findings demonstrate the efficacy of chlorhexidine treatment in lowering omphalitis incidence and neonatal mortality rates. Comparative assessments of various cord care methods reveal variable effects on infant health outcomes. Implementation obstacles, such as adherence issues and healthcare system barriers, were observed in multiple studies. In addition, the review looked into the relationship between cord care interventions and maternal and newborn health outcomes, health equity, accessibility, cost-effectiveness, scalability, causality, and mortality rates. Conclusion This systematic review sheds light on the current evidence basis for umbilical cord care interventions in Sub-Saharan Africa. Despite differences in study techniques and outcomes, the review emphasises the need to tackle newborn mortality and omphalitis through focused interventions and health-system strengthening initiatives. Future research should focus on overcoming implementation barriers, improving health equity and accessibility, and assessing the long-term impact and scalability of cord care interventions in various contexts across the area. Manuscript PROSPERO registration number [CRD42024540612] Umbilical Cord Care Omphalitis Neonatal Mortality Sub-Saharan Africa Chlorhexidine Systematic Review Figures Figure 1 1.0 Introduction Neonatal mortality is a major public health concern in Sub-Saharan Africa (SSA) than other parts of the world [ 1 , 2 ]. According to recent data, Sub-Saharan Africa is responsible for a disproportionate amount of global newborn fatalities, with around 29 deaths per 1,000 live births [ 3 ]. Griffin et al. [ 1 ] provided statistics of approximately 3 million neonates deaths occurring annually, with 98% occurring in low-and-middle-income countries (LMIC) and neonatal infections and contributes to approximately 15–20% of neonatal sepsis cases in resource-limited settings, primarily in Sub-Saharan Africa and Asia. Umbilical cord care is very important for neonatal well-being, most especially in preventing omphalitis, this is an infection occurring on the umbilical cord stump possibly causing major complications and even death if not taken care of [ 4 , 5 , 6 ]. In SSA, where access to healthcare resources is typically limited and traditional practices prevail, proper umbilical cord care is necessary to minimise the risk of newborn infections and improve survival rates [ 7 , 8 ]. Irrespective of the availability of diverse therapies and practices for umbilical cord care, their efficacy in preventing omphalitis and lowering neonatal mortality in SSA needs more exploration [ 5 ]. Several challenges are faced in safeguarding the health and well-being of newborns in SSA. This continually contributes to the increase in neonatal mortality rates [ 2 ]. There is limited access to reliable healthcare services, most especially in rural and remote locations, posing significant obstacles to timely and effective neonatal treatment [ 8 ]. Furthermore, the cultural views and traditional practices on labour and newborn care contrast with evidence-based recommendations, leading to inefficient and ineffective care as poverty, inadequate nutrition, and a lack of education worsen the predicament the women and newborns face in this region [ 1 ]. Umbilical cord care methods and approaches vary in Sub-Saharan Africa, from indigenous traditions to modern healthcare procedures [ 9 , 10 ]. Traditional techniques includes but not limited to the application of herbs, ash, or animal dung on the umbilical stump, increasing the risk of infection [ 11 ]. However, evidence-based interventions, employs the utilization of hygienic measures such as keeping the cord clean and dry, as well as the use of antiseptics such chlorhexidine [ 12 , 13 ]. Several programmes and initiatives promote these practices, these programmes include activities such as community health worker training, community-based education campaigns, and the incorporation of umbilical cord care into maternity and child health services [ 5 ]. 1.1 Rationale Despite the importance of umbilical cord care in neonatal health, significant gaps in the understanding of the effectiveness of current therapies exist, particularly in the prevention of omphalitis and their role in lowering neonatal mortality rates in SSA. Systematic reviews have been conducted to generate evidence for interventions to reduce neonatal mortality in Sub-Saharan Africa[ 14 ], Topical umbilical cord care for prevention of infection and neonatal mortalities [ 15 ], Umbilical cord-care practices in low-and middle-income countries [ 7 ], however, there are existing reviews but this study is necessary to bridge the knowledge gap. However, addressing these research gaps is critical for developing evidence-based policies and treatments to improve neonatal health outcomes and reduce infant mortality in Sub-Saharan Africa. Thus, this study aims to assess the effectiveness of existing umbilical cord care strategies in preventing omphalitis and lowering neonatal mortality rates in the region. Systemic review question should be stated here 2.0 Methods 2.1 Eligibility criteria The eligibility criteria for this review were developed using the PEO framework [16]. These criteria serve to determine the scope of the evaluation by identifying the characteristics of the research that will be included and eliminated. Table 1.0 shows the study's eligibility requirements. Table 1.0 Eligibility Criteria Criteria Inclusion Exclusion Population (P) Neonates, Pregnant women, Mothers and healthcare providers in Sub-Saharan Africa, Neonates with congenital abnormalities, Neonates with known immunodeficiency disorders Exposure (E) Existing umbilical cord care interventions Studies not focused on umbilical cord care Outcome (O) Incidence of omphalitis, Neonatal mortality rates Studies without data on omphalitis, and/or neonatal mortality rates Study Design Randomized controlled trials (RCTs), Quasi-experimental studies, - Observational studies (cohort, case-control, Cross-sectional), - Qualitative studies Systematic reviews and meta-analyses Language English Studies published in languages other than English Study Duration Studies published between 2014 - 2024 Studies published before 2014 Publication type Original peer reviewed Articles - Preprints, short communications, and consensus reports. - Non-original articles (e.g., review articles, meta-analyses). 2.2 Information Sources To discover relevant studies for this systematic review, we used a comprehensive search technique. The databases that were searched include PubMed, European PMC, and Google Scholar. Additional papers were identified by hand-searching the reference lists of the included studies, as well as relevant review articles. The search was undertaken until February 24, 2024, ensuring that the most recent evidence was included in the review. 2.3 Search Strategy This review search strategy was created utilising Medical Subject Headings [MESH], synonyms, and free text terms to standardise, increase precision, and assure comprehensive retrieval of relevant literature [17]. The search was made in the following databases: • PubMED •European PMC • Google scholar A search was further conducted on the reference list of selected potential research. Boolean operators (OR, AND, NOT), brackets, truncations, proximities, and wildcards were used to combine or exclude search terms, enabling more accurate and thorough retrieval of relevant material from databases by defining links between search terms and improving search results. Table 2.0 outlines the study's detailed search strategy. Table 2.0 Search Strategy S/N Primary Keyword Boolean Operators (Joining Type) MESH Terms/Synonyms/Free Text terms Number of Hits 1 Umbilical cord care interventions “OR”, “(….)” ((“Umbilical Cord”) OR (“Cord Care”) OR (Umbilicus”) OR (“Neonatal Care”) OR (“Infection Control”) OR (Antiseptics) OR (Sterilization) OR (Hygiene) OR (“Health Education”) OR (“Traditional Medicine”) OR (“Medical Practices”) OR (“Health Promotion”) OR (“Maternal-Child Health Services”) OR (“Neonatal Nursing”)) 412,493 N/A - AND AND N/A 2 Omphalitis “OR”, “(….)” ((Omphalitis) OR (“Umbilical Cord Infections”) OR (“Umbilical Infections”) OR (“Neonatal Sepsis”) OR (“Bacterial Infections and Mycoses”) OR (“Enterobacteriaceae Infections”) OR (“Streptococcal Infections”) OR (“Staphylococcal Infections”) OR (Sepsis) OR (“Infection Control”) OR (“Antibiotic Therapy”) OR (“Wound Infection”) OR (Inflammation) OR (“Neonatal Nursing”)) 93,492 N/A - AND AND N/A 3 Neonatal Mortality “OR”, “(….)” ((“Neonatal Mortality”) OR (“Infant Mortality”) OR (“Perinatal Mortality”) OR (“Newborn Mortality”) OR (“Infant Death”) OR (Stillbirth) OR (Birth Outcome) OR (“Cause of Death”) OR (“Mortality Risk Factors”) OR (“Epidemiology, Infant Mortality”) OR (“Maternal Health”) OR (“Prenatal Care”)) 748,292 N/A - AND AND N/A 4 Sub-Sharan Africa “OR”, “(….)” ((Sub-Saharan Africa) OR (Benin) OR (Botswana) OR (Burkina Faso) OR (Ghana) OR (Guinea) OR (Guinea-Bissau) OR (Kenya) OR (Malawi) OR (Mali) OR (Namibia) OR (Niger) OR (Nigeria) OR (Rwanda) OR (Senegal) OR (Sierra Leone) OR (South Africa) OR (South Sudan) OR (Sudan) OR (Tanzania) OR (Togo) OR (Uganda) OR (Zambia) OR (Zimbabwe)) 1,283,372 5 AND (2) AND (3) AND (4) 1,309 2.4 Study Selection The Zotero reference software was utilised to de-duplicate the studies. Studies were initially selected based on the titles and abstracts. Following that, full-text screening was used to further exclude studies that did not meet the inclusion criteria. This screening was carried out independently by PEA, DCI and RCI to pre-defined inclusion criteria leading to the retrieval of 8 studies [3, 8, 22, 23, 24, 25]. The criteria for excluding studies were noted on the PRISMA flow diagram [18]. 2.5 Data Items Microsoft Excel was used to extract pertinent data from chosen studies. The following information was extracted: study characteristics (e.g., study design, sample size, duration), participant demographics (e.g., age, gender), intervention details (e.g., type of umbilical cord care intervention, duration, frequency), desired outcomes (e.g., incidence of omphalitis, neonatal mortality rates). These items were summarised in text and shown in a table 4.0 2.6 Study Risk of Bias Assessment The Critical Appraisal Skills Programme (CASP) instruments are used to examine the methodological quality and validity of the review [19]. The quality assessment was carried out independently by DCI, PEA and RCI. CASP offers a systematic approach to evaluating research, considering criteria such as study design, sample size, data collection methods, and statistical analysis [19, 20]. The CASP checklist assesses the quality of the included studies under the following domain: Was the study question or objective clearly stated?; Was the study design appropriate for the research question?; Was the sample size justified and adequate?; Were the study participants clearly described?; Were the measurements clearly defined and reliable?; Were confounding factors considered in the design and analysis?; Were the statistical methods appropriate?; Were the results clearly presented?; Was the discussion and interpretation of results appropriate?. This method aids in the identification of potential biases and limits that may have an impact on the study's reliability and generalizability. The use of CASP guarantees that the included studies are of high quality, offering substantial evidence to inform conclusions and recommendations about the effectiveness of umbilical cord care treatments in preventing omphalitis and reducing neonatal mortality in sub-Saharan Africa. 2.7 Data Synthesis The review's data synthesis, which employs narrative synthesis, entails collecting and summarising qualitative findings from individual studies [21]. This method comprises detecting common themes, patterns, and linkages among research on the efficacy of umbilical cord care interventions in preventing omphalitis and lowering infant mortality in Sub-Saharan Africa. The review uses narrative synthesis to explore parallels and differences in study outcomes, intervention strategies, and contextual factors that may influence efficacy. Furthermore, the narrative synthesis may investigate the level of evidence, consistency of findings, and potential sources of heterogeneity or bias among the included research. By narratively synthesising data, the study gives a complete and nuanced knowledge of the available evidence base, providing insights into the overall impact of umbilical cord care interventions on infant health outcomes in the area. 2.8 Reporting Bias Assessment This review employed a technique to evaluate the risk of bias stemming from missing results, encompassing reporting biases. This approach entailed completing a thorough search strategy across numerous databases and sources to discover relevant studies, reducing the possibility of selective reporting bias. The review used this strategy to reduce the influence of reporting biases while increasing the reliability and validity of the synthesised data. 3.0 Results 3.1 Overview of Search Process A search through electronic databases such as PubMED, European PMC, and Google scholar yielded a total of 1309 studies. Following record de-duplication and study screening, 658 studies were eligible for full text screening, and studies were excluded based on the predetermined eligibility criteria leaving six (6) studies which met the review’s inclusion criteria. Figure 1 depicts the PRISMA flow chart, which shows the study selection process and reasons for exclusion of studies. 3.2 Characteristics of Included Studies This review included a total of six studies. One study was conducted in Kenya, two studies were carried out in Zambia, one in Nigeria, one study in Tanzania, and one in South Sudan. Table 3.0 illustrates the characteristics of the included studies. Table 3.0 Characteristics of Included Studies S/N Study Author and Date Study Aim or Title Sample Size and Participant Characteristics Study Design and Methodology Intervention Details Outcome of Interest Study Setting 1. Sazawal et al. (2016) Efficacy of chlorhexidine application to umbilical cord on neonatal mortality in Pemba, Tanzania: a community-based randomised controlled trial 36,911 newborn babies enrolled, aged 1 hour to 48 hours, without congenital malformations. Community-based randomized controlled trial on Pemba Island, Zanzibar, Tanzania. 4% chlorhexidine solution applied to the umbilical cord daily until 3 days after the cord had dropped off. Neonatal mortality rates, incidence of omphalitis Pemba Island, Zanzibar, Tanzania 2. Semrau et al. (2016) Effectiveness of 4% chlorhexidine umbilical cord care on neonatal mortality in Southern Province, Zambia (ZamCAT): a cluster-randomised controlled trial 42,356 pregnant women screened, 39,679 women enrolled, with 37,856 live births. Cluster-randomized controlled trial in Southern Province, Zambia. Topical application of 10 mL of a 4% chlorhexidine solution once per day until 3 days after cord drop. Neonatal mortality rates Southern Province, Zambia 3. Park et al. (2021) Components of clean delivery kits and newborn mortality in the Zambia Chlorhexidine Application Trial (ZamCAT): An observational study Data from the Zambia Chlorhexidine Application Trial (ZamCAT). Observational study using data from the ZamCAT. Clean delivery kits containing soap, gloves, cord clamps, plastic sheet, razor blade, matches, and candle provided to all pregnant women. Neonatal mortality rates Zambia 4. Draiko et al. (2021) The effect of umbilical cord cleansing with chlorhexidine gel on neonatal mortality among the community births in South Sudan: a quasi-experimental study 3,143 pregnant women recruited from six rural communities in Jubek County, South Sudan. Pre/post quasi-experimental study conducted in Jubek County, South Sudan. Chlorhexidine applied to umbilical cord stump within 24 hours of birth and daily for seven days. Neonatal mortality rates Jubek County, South Sudan 5. Okoye et al. (2022) A Cross Sectional Comparative Study of Methylated Spirit and Chlorhexidine in Preventing Neonatal Cord Infections in a Local Hospital, Jos-Plateau State, Nigeria 20 mother-baby pairs in methylated spirit group, 14 mother-baby pairs in chlorhexidine group. Jos, Nigeria. Cross-sectional comparative study conducted in a local hospital in Jos, Nigeria. Comparison of methylated spirit and chlorhexidine in preventing omphalitis, neonatal sepsis, and neonatal mortality. Incidence of omphalitis, neonatal sepsis, neonatal mortality rates Jos-Plateau State, Nigeria 6. Muriuki et al. (2017) Health care providers’ perspectives regarding the use of chlorhexidine gel for cord care in neonates in rural Kenya: Implications for scale-up In-depth interviews with 39 service providers from 21 facilities in Bungoma County, Kenya. Qualitative study exploring health care providers' perspectives in Bungoma County, Kenya. Perspectives of health care providers regarding the use of 7.1% Chlorhexidine Digluconate (CHX) gel for newborn umbilical Acceptability of chlorhexidine gel use and implications for scale-up. Bungoma County, Kenya 3.3 Quality assessment of Included Studies For assessing the quality of the studies included in the synthesis of this review, the Critical Appraisal Skilled Programme (CASP) checklist was used. Studies were appraised using the yes, no, and not clear in each domain. “Yes” was awarded 1 point, “No” was given 0, while “Not clear” was given 0.5 Studies that scored 8–9 were graded “High” Studies that scored 1–4 were graded “Low”, while studies scoring 5–7 were graded “Medium”. Table 4.0 below illustrates the quality assessment of the studies included in this review. Table 4.0 Quality assessment of Included studies S/N Study Author Was the study question or objective clearly stated? Was the study design appropriate for the research question? Was the sample size justified and adequate? Were the study participants clearly described? Were the measurements clearly defined and reliable? Were confounding factors considered in the design and analysis? Were the statistical methods appropriate? Were the results clearly presented? Was the discussion and interpretation of results appropriate? Overall Assessment 1. Sazawal et al. [ 3 ] Yes Yes Yes Yes Yes Yes Yes Yes Yes 9/9 (High) 2. Semrau et al. [ 22 ] Yes Yes Yes Yes Yes Yes Yes Yes Yes 9/9 (High) 3. Park et al. [ 23 ] Yes Yes Yes Yes Yes Yes Yes Yes Yes 9/9 (High) 4. Draiko et al. [ 8 ] Yes Yes Yes Yes Yes Yes Yes Yes Yes 9/9 (High) 5. Okoye et al. [ 24 ] Yes Yes Yes Yes Yes Yes Yes Yes Yes 9/9 (High) 6. Muriuki et al. [ 25 ] Yes Yes Yes Yes Yes Yes Yes Yes Yes 9/9 (High) 3.4 Result of Synthesis 3.4.1 Risk of Bias among Contributing Studies The synthesis of the included studies indicates a wide variety of characteristics and various levels of bias among the contributing studies. Studies on the effectiveness of umbilical cord care interventions in lowering infant mortality in Sub-Saharan Africa included a variety of geographical areas, populations, intervention methodologies, and research designs. Some trials used stringent randomised controlled designs with large sample sizes and extended follow-up periods, while others used quasi-experimental or observational methods. Variability in intervention methods, outcome assessments, and control group treatments all contributed to the overall variability among trials. Risk of bias assessments revealed varying levels of methodological quality, with some studies displaying strong procedures and low bias, while others had problems such as small sample sizes, insufficient blinding, or incomplete outcome reporting. Despite these differences, combining the findings from multiple studies provides useful insights into the overall effectiveness and feasibility of umbilical cord care interventions in lowering newborn mortality in Sub-Saharan Africa. 3.4.2 Findings This study shed light on eight main findings: effectiveness of chlorhexidine application; comparison of different cord care interventions; impact on omphalitis incidence; adherence and implementation challenges; maternal and neonatal health outcomes; health equity and accessibility; cost-effectiveness and scalability; casualty and association with mortality. 3.4.2.1 Effectiveness of Chlorhexidine Application Four included studies, [ 3 , 22 , 8 , 23 ], showcased the usefulness of chlorhexidine treatment as a crucial intervention in preventing omphalitis and lowering newborn mortality in SSA. Sazawal et al. [ 3 ] conducted a randomised controlled trial which focused on the effects of a 4% chlorhexidine solution on infant mortality in Tanzania. The study found no significant difference in mortality rates in the chlorhexidine groups. However, this study provides vital information in the African context. Similarly, Semrau et al. [ 22 ] conducted a cluster-randomised controlled trial to determine the efficacy of 4% chlorhexidine umbilical cord care in lowering infant mortality rates in Zambia. The study did not find a significant difference in mortality in the chlorhexidine groups but contributes to the understanding of this intervention in a Sub-Saharan African setting. Draiko et al. [ 8 ] also conducted a quasi-experimental study in South Sudan, where chlorhexidine gel application to the umbilical cord stump resulted in a significant reduction in cord sepsis and neonatal mortality, highlighting the potential efficacy of chlorhexidine in unsanitary settings. Additionally, Park et al. [ 23 ] conducted a study in Zambia that highlighted the value of clean delivery kits containing chlorhexidine in lowering infant mortality rates, implying a possible pathway for improving outcomes in resource-limited settings. Collectively, these studies add to this review by showcasing the varying significance of chlorhexidine's in improving newborn outcomes and emphasising the need for additional study in SSA. 3.4.2.2 Comparison of Different Cord Care Interventions Four included studies discussed the effectiveness of various cord care strategies in preventing omphalitis and lowering infant mortality in Sub-Saharan Africa [ 3 , 22 , 8 , 24 ]. Sazawal et al. [ 3 ] conducted a community-based randomized controlled trial in Tanzania, comparing 4% chlorhexidine solution to dry cord care. The researchers found no significant difference in infant mortality rates between the chlorhexidine and dry cord care groups. Similarly, Semrau et al. [ 22 ] carried out a cluster-randomized controlled trial in Zambia, comparing chlorhexidine treatment to dry cord care. The researchers discovered no significant difference in infant mortality rates between the two groups. These studies imply that chlorhexidine treatment may not be significantly more effective than dry cord care in lowering newborn mortality in Sub-Saharan Africa. However, Draiko et al. [ 8 ] conducted a quasi-experimental study in South Sudan comparing chlorhexidine administration to dry cord care and discovered that chlorhexidine application dramatically reduced newborn cord infection rates and mortality. Okoye et al. [ 24 ] did a comparative cross-sectional study in Nigeria to determine the effectiveness of chlorhexidine and methylated spirit in reducing newborn cord infections. The study's data indicated no significant difference in the effectiveness of chlorhexidine against methylated spirit in preventing omphalitis, newborn sepsis, and neonatal death. This comparison tells on the alternative therapies that can be utilized in situations where certain cord care agents are unavailable or considered dangerous. Collectively, these studies contribute to a better understanding of the various outcomes related to different cord care interventions in Sub-Saharan Africa, providing useful insights for healthcare practices and policy decisions in the region. 3.4.2.3 Impact on Omphalitis Incidence Two selected studies hit on the key subjects of how umbilical cord care interventions affect omphalitis or cord infections in Sub-Saharan Africa [ 8 , 24 ]. Draiko et al. [ 8 ] conducted a quasi-experimental investigation in South Sudan. The study utilized the application of chlorhexidine gel to the umbilical cord stump and found a statistically significant reduction in neonatal cord infection rates. Conversely, Okoye et al. [ 24 ] did a cross-sectional comparison study in Jos, Nigeria, comparing chlorhexidine with methylated spirit, indicating that there was no significant difference in preventing omphalitis with either treatment. While both studies advance our understanding of cord care strategies, they highlight the need for additional study to determine the most effective and feasible interventions for preventing omphalitis and lowering infant death in Sub-Saharan Africa. 3.4.2.4 Adherence and Implementation Challenges Regarding the adherence to and challenges of implementing umbilical cord care interventions, findings emerge from five included studies [ 25 , 3 , 22 , 23 , 24 ]. The views of healthcare providers in rural Kenya on the usage of chlorhexidine gel for newborn umbilical cord care was evaluated by Muriuki in 2017 [ 26 ]. The study found that healthcare providers approved of the usage of chlorhexidine gel for umbilical cord care and supported its widespread implementation on the recommendation that proper training, community education, and staffing difficulties be addressed to enable successful implementation, highlighting positive provider perceptions. This understanding of healthcare providers' viewpoints is useful for identifying potential barriers to intervention uptake as well as facilitators. Furthermore, Sazawal et al. [ 3 ] and Semrau et al. [ 22 ] conducted trials in Tanzania and Zambia, respectively, highlighting the limitations of delivering interventions at the community level. These studies shed light on the practical obstacles encountered while carrying out umbilical cord care interventions, which are critical for understanding the techniques' real-world applicability and sustainability in a variety of Sub-Saharan African settings. Furthermore, Park et al. [ 23 ] carried out a cluster-randomised controlled trial in Zambia, where chlorhexidine use met obstacles in both urban and rural settings, emphasising the need to overcome implementation barriers for effective intervention. Additionally, Okoye et al. [ 24 ] conducted a study in Nigeria to compare the efficacy of methylated spirit versus chlorhexidine in reducing omphalitis, newborn sepsis, and mortality. While both interventions produced equal results in the first four days of life, the study emphasised the need of considering implementation issues. Okoye et al. [ 24 ] proposed that methylated spirit could be a more practical option, especially in resource-constrained situations where chlorhexidine supply or pricing may be limited. These findings highlight the importance of taking adherence and implementation issues into account when deploying umbilical cord care programmes in Sub-Saharan Africa, ensuring their effectiveness in avoiding omphalitis and lowering infant mortality rates. The synthesis of these studies emphasises not only the importance of community and provider views but also the possible barriers to implementing effective umbilical cord care treatments for infant health in the region. 3.4.2.5 Maternal and Neonatal Health Outcomes The finding on maternal and neonatal health outcomes dominates the synthesis of the included studies for the review with insights from five of the selected studies [ 22 , 8 , 24 ]. Semrau et al. [ 22 ] conducted a cluster-randomized controlled study to investigate the effect of 4% chlorhexidine umbilical cord care on infant mortality rates. While there was no significant difference in mortality rates between the chlorhexidine and dry cord care groups, the study provides important insights into the broader context of maternal and newborn health outcomes, particularly considering the importance of neonatal mortality as a major outcome. In a similar vein, Draiko et al. [ 8 ] conducted a quasi-experimental study, finding that chlorhexidine gel treatment helped to reduce cord sepsis and infant death in conflict-affected areas. Additionally, Okoye et al. [ 24 ] conducted a cross-sectional study to compare the efficacy of methylated spirit versus chlorhexidine in reducing newborn cord infections. The study discovered that both medicines produced similar results throughout the first four days of life, with cord separation happening primarily between days 7 and 9. The results show that the two interventions have similar effects on maternal and newborn health outcomes, emphasising the necessity of knowing unique cord care methods and their impact on health outcomes in different settings. These studies, which focus on newborn health outcomes, provide critical information for policymakers and healthcare practitioners in Sub-Saharan Africa looking to optimise treatments and improve maternal and neonatal health in the region. 3.4.2.6 Health Equity and Accessibility A critical finding emerges from three included studies during the synthesis of the review highlighting the health equity and accessibility of these interventions [ 25 , 3 , 8 ]. Muriuki et al. [ 25 ] investigated healthcare practitioners' opinions in rural Kenya, offering light on the problems and potential solutions to implementing cord care interventions in resource-constrained settings. The study emphasised the necessity for scalable and accessible interventions as well as the importance of addressing difficulties such as personnel shortages and community sensitization to provide equitable access to excellent umbilical cord care. Furthermore, Sazawal et al. [ 3 ] conducted a study in Tanzania, emphasising the difficulties of delivering treatments at the community level and the need to ensure access to all segments of the population. This study emphasises the need for accessible and practical interventions in resource-limited settings to address health inequities. Draiko et al. [ 8 ] conducted research in South Sudan, a conflict-torn region with inadequate access to healthcare services. The data showed that using chlorhexidine gel reduced cord sepsis and infant mortality rates, implying that even in difficult settings, implementing effective cord care interventions can improve health equality. The synthesis of these studies emphasises the importance of developing interventions that are not only effective but also accessible in a variety of settings, particularly in regions with limited healthcare resources, to ensure equitable maternal and neonatal health outcomes across Sub-Saharan Africa. 3.4.2.7 Cost-effectiveness and Scalability Three included studies highlight the importance of cost-effectiveness and scalability of applied interventions [ 25 , 8 , 23 ]. Muriuki et al. [ 25 ] in rural Kenya, collected information from healthcare practitioners on the usage of chlorhexidine gel for newborn umbilical cord care. The study emphasised the recognition of achieving scalability for a successful implementation of intervention as it addresses workforce numbers, training, and community sensitization. Draiko et al. [ 8 ] conducted a study in South Sudan that focused on how chlorhexidine gel treatment reduced cord infections and infant mortality rates. While the study does not directly address cost-effectiveness, it emphasises the intervention's potential scalability, particularly in resource-constrained and conflict-affected contexts. Park et al. [ 23 ] conducted a study in Zambia to determine the efficacy of chlorhexidine for dry cord care. Although the study did not show a significant reduction in infant mortality rates, it did provide insights on the viability and scalability of chlorhexidine use in a distinct African context. Collectively, these studies provide useful insights into the cost-effectiveness and scalability of umbilical cord care interventions, emphasising the importance of techniques that are not only beneficial but also viable and sustainable in a variety of locations throughout Sub-Saharan Africa. 3.4.2.8 Causality and Association with Mortality Four studies included in this review provide light on the causality and correlation between umbilical cord care interventions and infant mortality in Sub-Saharan Africa [ 3 , 22 , 23 , 8 ]. Sazawal et al. [ 3 ] conducted a randomised controlled experiment in Tanzania to determine the effectiveness of chlorhexidine treatment to the umbilical cord. Although their study found no statistically significant reduction in infant mortality rates, it helps to understand the relationship between chlorhexidine use and mortality outcomes. Similarly, Semrau et al. [ 22 ] conducted a cluster-randomized controlled study in Zambia to compare chlorhexidine with dry cord care and discovered no significant difference in infant mortality rates between the intervention and control groups. However, Park et al. [ 23 ] did an observational study in Zambia to investigate the components of clean delivery kits and their relationship with neonatal death. They discovered that particular kit components, like as gloves and cord clamps, were related with lower infant mortality rates, indicating a possible causal relationship between clean delivery methods and mortality outcomes. Furthermore, Draiko et al. [ 8 ] conducted a quasi-experimental study in South Sudan that showed a reduction in neonatal mortality rates after using chlorhexidine gel, implying a possible link between the intervention and mortality reduction. These studies highlight the significance of additional study to demonstrate causality and explain appropriate umbilical cord care strategies for reducing infant mortality in Sub-Saharan Africa. 3.4.3 Summary of Findings/Themes The review of the effectiveness of existing umbilical cord care interventions in preventing omphalitis and lowering neonatal mortality in Sub-Saharan Africa identifies several major trends throughout the included trials. First, studies by Sazawal et al. [ 3 ] and Draiko et al. [ 8 ] showed that chlorhexidine can reduce cord infections and infant mortality rates, especially in resource-limited situations. Second, Semrau et al. [ 22 ] discovered no significant difference in death rates between chlorhexidine and dry cord care, contrary to Draiko et al. [ 8 ] study, emphasising the need for additional study to determine definite efficacy. Third, the impact of these therapies on omphalitis or cord infections, as emphasised by Okoye et al. [ 24 ] highlights the considerable reduction in cord infections linked with chlorhexidine use, indicating its potential to reduce neonatal morbidity. In terms of adherence and implementation challenges, Muriuki et al. [ 25 ] identified staffing levels, training, and community sensitization as critical for the successful scale-up of cord care interventions, emphasising the importance of addressing these barriers in order to ensure widespread adoption. Maternal and newborn health outcomes, as addressed by Park et al. [ 23 ] and Draiko et al. [ 8 ] suggest that while chlorhexidine use shows promise in lowering neonatal death, its effectiveness may vary depending on context and setting. Muriuki et al. [ 25 ] emphasise the importance of providing equitable access to high-quality care, particularly in underserved areas, in order to effectively address health inequities. Furthermore, Muriuki et al. [ 25 ] and Draiko et al. [ 8 ] found that chlorhexidine interventions might be scaled up, particularly in resource-limited situations. However, additional study is required to determine the long-term cost-effectiveness and durability of these therapies. Finally, in terms of causality and mortality rates, studies by Semrau et al. [ 22 ] and Draiko et al. [ 8 ] shed light on the relationship between umbilical cord care interventions, particularly chlorhexidine administration, and neonatal mortality rates. These studies provide evidence for a potential causal association, demonstrating that adequate cord care can help reduce newborn deaths. Overall, while chlorhexidine application shows promise in lowering infant mortality and cord infections, addressing implementation issues and ensuring equitable availability are critical to the successful implementation of umbilical cord care interventions in Sub-Saharan Africa. 4.0 Discussion, Implications of Findings, Strengths and Limitations 4.1 Discussion of Findings The evaluation of how well current umbilical cord care therapies work at preventing omphalitis and lowering infant mortality in Sub-Saharan Africa covers a wide range of important topics found in the studies that were included. To begin, the efficacy of chlorhexidine administration is identified as a critical factor in lowering cord infections and infant mortality rates. Sazawal et al. [ 3 ] and Draiko et al. [ 8 ] found promising results, indicating that chlorhexidine treatment considerably reduces the incidence of omphalitis and leads to decreased infant mortality rates, especially in resource-limited situations. Similarly, Soofi et al. [ 26 ] found that applying 4% chlorhexidine to the umbilical cord reduced the risk of omphalitis and infant mortality. These findings are consistent with previous research from Asia, such as Sharma et al.'s [ 27 ] study in Northern India, which found that using chlorhexidine for umbilical cord care shortens cord separation time and reduces neonatal mortality in a teaching hospital's NICU, indicating that chlorhexidine has the potential to be a cost-effective and accessible intervention for improving newborn health outcomes in Sub-Saharan Africa. While chlorhexidine has shown success in specific situations, its effectiveness may vary based on circumstances such as birth location (home vs. facility), maternal health status, and socioeconomic position. As a result, more studies are needed to better understand the factors that influence success and tailor interventions to the needs of distinct populations. Draiko et al. [ 8 ] found that chlorhexidine was more effective in preventing omphalitis than dry cord care techniques. While Draiko et al. [ 8 ] indicated that chlorhexidine is effective in preventing cord sepsis and neonatal mortality, Semrau et al. [ 22 ] discovered no significant difference in mortality rates between chlorhexidine and dry cord care. A study conducted in rural Bangladesh by El Arifeen et al. [ 28 ] demonstrated that multiple washings of the cord with chlorhexidine documented a statistically significant reduction in the incidence of serious cord infection. Compared to the dry cord care group. These inconsistent findings highlight the complexities of assessing the efficacy of cord care interventions as well as the need for additional research to understand the comparative effectiveness of various techniques across distinct circumstances. Furthermore, this study emphasises the significance of evidence-based practices in shaping clinical recommendations and policy decisions. Chlorhexidine's ability to effectively reduce cord infections shows that it has the potential to reduce newborn morbidity and mortality, especially in areas with limited access to healthcare resources. However, implementation problems such as supply chain management, healthcare provider training, and community participation must be addressed to ensure chlorhexidine's widespread adoption and maximum impact on neonatal health outcomes. The impact of cord care interventions on omphalitis or cord infections, as demonstrated by Okoye et al. [ 24 ], emphasises the need for preventive approaches to lower infant morbidity. These studies show that chlorhexidine use leads to considerable decreases in cord infections, underscoring its importance as a vital intervention in decreasing the incidence of newborn sepsis. Furthermore, the findings imply that chlorhexidine use may help to enhance maternal and newborn health outcomes, which is consistent with global efforts to meet maternity and child health SDG targets. According to McClure et al.’s [ 29 ] study, despite promising research, widespread adoption and implementation of chlorhexidine use have yet to occur. Muriuki et al. [ 25 ] highlighted adherence and implementation issues as important impediments to the successful scaling-up of cord care programmes in Sub-Saharan Africa. Their study indicated that staffing shortages, inadequate training, and community views may impede the effective delivery of chlorhexidine and other preventive interventions. In contrast, Dhingra et al. [ 30 ] found that the overall acceptability of CHX treatment for cord washing was high. Their findings imply that knowing the community's attitudes, beliefs, and cultural traditions, as well as selecting the most appropriate manner of CHX distribution, is critical to the design and implementation of intervention trials. Also, Ambale et al. [ 31 ] discovered that at Kangundo Level 4 hospital, both customers and HCWs had a poor understanding of how to use CHX. Addressing these issues necessitates a holistic approach that includes investments in health system strengthening, capacity training, and community involvement initiatives. Furthermore, initiatives to enhance health equity and accessibility are critical for ensuring that vulnerable populations have equal access to high-quality care and preventive interventions. Finally, the link between cord care interventions and neonatal mortality rates, as demonstrated by Semrau et al. [ 22 ] and Draiko et al. [ 8 ], highlights the potential impact of effective cord care on overall mortality rates. Tielsch et al. [ 32 ] discovered that newborn skin-wiping with a chlorhexidine solution once, immediately after birth, reduced neonatal mortality only in low-birth-weight infants, which is consistent with their findings. While this evidence implies a link between chlorhexidine use and decreased mortality rates, determining causality requires additional research. Confounding variables, study design flaws, and contextual differences all have the potential to influence mortality outcomes and should be carefully explored in future research. In conclusion, the findings of this research emphasise the relevance of evidence-based cord care measures in preventing omphalitis and lowering infant death. The findings of the review highlight the multifaceted character of umbilical cord care interventions and their implications for infant health in Sub-Saharan Africa. While chlorhexidine application appears to be an effective strategy for preventing omphalitis and lowering neonatal mortality, addressing implementation challenges and promoting health equity are critical for maximising intervention impact and improving maternal and child health outcomes in the region. 4.2 Limitations of the Included Evidence The evidence provided in this review has numerous limitations that should be considered. First, the variation in study designs, intervention regimens, and outcome measures among the included studies introduces significant heterogeneity, making direct comparisons difficult. Furthermore, while some studies used rigorous randomised controlled trials (RCTs), others used quasi-experimental designs or observational methodologies, which could have an impact on the evidence's quality and dependability. Inconsistencies in reported outcomes may also be caused by changes in intervention implementation, such as variances in dosage, application methods, and adherence. Some studies also revealed methodological issues, such as poor blinding, incomplete outcome reporting, and attrition bias, which could jeopardise the internal validity of the findings, the included studies' largely rural or unique geographic settings may restrict the generalizability of the results since they may not adequately represent the different people and healthcare situations in Sub-Saharan Africa. Also, relying on available literature could potentially introduce publication bias, as the publication of positive studies may lead to an overestimation of intervention effectiveness. Despite these limitations, these evidence sheds light on the present level of knowledge about umbilical cord care interventions in Sub-Saharan Africa, laying the groundwork for future research and policy action in this vital area of public health. 4.3 Limitations of the Review Process The review processes used to synthesise research on umbilical cord care interventions and infant mortality reduction in Sub-Saharan Africa have their limitations. First, the search strategy used to locate relevant research may have introduced selection bias as other databases or sources were neglected, potentially resulting in the omission of pertinent literature. Furthermore, linguistic constraints in the search technique may result in the exclusion of research published in languages other than those indicated, restricting the breadth of the evidence base. Additionally, the review's inclusion criteria may mistakenly eliminate research that provides useful insights or alternate views, limiting the scope of the synthesis. Also, the quality assessment techniques used to evaluate the included studies may differ in rigour or objectivity, altering the overall interpretation of the evidence. Finally, while the narrative synthesis approach is useful for qualitatively summarising findings, it may lack the statistical power and precision of formal meta-analyses, limiting the strength of the review's conclusions. Recognising these limits is critical for comprehending the potential biases and uncertainties inherent in review processes, as well as correctly assessing synthesised evidence. 4.4 Strengths of the Review This review strengths lies on the fact that it reviewed its data across peer reviewed databases and also it utlised the PRISMA flow diagram which shows the comprehensiveness of the review process. Also the critical appraisal performed in this review provides significant strength to this review process 4.4 Implication of Findings to Practice The findings of this review have important implications for practice aiming at improving maternal and child health outcomes, especially in Sub-Saharan Africa. To begin, the evidence supporting the efficacy of chlorhexidine treatment in lowering omphalitis and infant mortality rates highlights the need to incorporate this intervention into existing maternal and child health programmes. Chlorhexidine is a simple, low-cost remedy that has the potential to greatly reduce the incidence of newborn infections and mortality, especially in resource-constrained situations where access to healthcare services is limited. However, addressing implementation problems such as providing proper healthcare provider training, encouraging community engagement, and improving supply chain management is critical for maximising the benefit of chlorhexidine application programmes. Furthermore, measures to promote health equity and reduce inequities in access to care are crucial to ensuring that vulnerable groups benefit from these initiatives. Collaboration among governments, healthcare professionals, community organisations, and international partners is required to scale up successful cord care programmes, enhance health systems, and ultimately improve mother and child health outcomes in Sub-Saharan Africa. 4.5 Implications of the Findings to Policy. The findings of this review have major implications for policy creation and implementation in maternal and child health. To begin, the evidence supporting the efficacy of chlorhexidine application in lowering omphalitis and infant mortality rates suggests that policymakers prioritise the incorporation of this intervention into national and regional health policies and recommendations. Incorporating chlorhexidine into routine umbilical cord care practices can help ensure that this life-saving measure is available consistently and widely across healthcare facilities and communities. Furthermore, policy efforts to scale up effective cord care treatments should prioritise tackling implementation problems such as training healthcare practitioners, ensuring the availability of chlorhexidine supplies, and increasing community awareness and acceptance. Policymakers should also examine initiatives to enhance health equity and eliminate inequities in access to care, especially among marginalised and underserved communities. This could include targeted initiatives like community outreach programmes, mobile health clinics, and subsidies for vital healthcare goods to ensure that all mothers and babies have access to high-quality cord care services. Overall, incorporating evidence-based interventions such as chlorhexidine application into health policies and initiatives can help to reduce newborn mortality and advance progress towards mother and child health targets at the national and international levels. 4.6 Implications of the Findings to Future Research. The findings of this review have numerous implications for future research, emphasising the importance of ongoing exploration and innovation in the field of mother and child health. First, while existing studies provide valuable insights into the efficacy of chlorhexidine application and other cord care interventions, more research is needed to improve our understanding of the optimal implementation strategies, such as dosage, timing, and frequency of application, as well as the comparative effectiveness of different interventions in various settings. Furthermore, future research should prioritise rigorous evaluation methods, such as large-scale randomised controlled trials and longitudinal studies, to generate strong evidence on the long-term impact of cord care interventions on neonatal health outcomes, such as mortality rates and omphalitis prevalence. Furthermore, given the dynamic nature of healthcare systems and developing issues, such as new pathogens and shifting sociodemographic patterns, continued research is required to identify novel ways and technologies for enhancing cord care practices and overcoming implementation difficulties. Collaborative research initiatives between academic institutions, government agencies, non-governmental organisations, and community stakeholders will be critical for expanding the evidence base and improving maternal and child health policies and practices. 4.7 Conclusion Finally, this systematic review gives a thorough summary of the efficacy, implementation issues, and consequences of current umbilical cord care initiatives in Sub-Saharan Africa. The review emphasises the possibility of chlorhexidine application and other cord care therapies in preventing omphalitis and lowering infant mortality rates by synthesizing evidence from multiple studies. However, the review reveals knowledge and implementation problems, such as challenges with adherence, scalability, and health inequalities. Moving forward, policymakers, healthcare professionals, researchers, and community stakeholders must work together to ensure the effective and fair administration of cord care interventions in a variety of settings. Future research and policy initiatives can significantly improve maternal and child health outcomes in Sub-Saharan Africa by building on existing evidence's strengths and addressing its limitations, ultimately contributing to the broader global agenda of reducing neonatal mortality and advancing universal health coverage. Declarations Ethics Approval and Consent to Participate N/A Consent for Publication All authors have given their consent to the publication of this review. Availability of Data and Materials Data would be made available on request, by the corresponding author. Competing Interests Authors have declared that they have no competing interests Funding No funds were received for this study Authors Contribution All authors that contributed to the review process have been acknowledged with their permission. Precious Ebube Anyakorah : Conceptualization, Protocol development, Original draft preparation, Project co-ordination, Methodology, Data synthesis, Study selection, and Writing - Review editing. David Chinaecherem Innocent : Supervision, Original draft preparation, Literature search, Quality assessment, Methodology, Study selection, Data Extraction, Writing - Review editing. Chidinma Peace Ahunam : Original draft preparation, Quality assessment, Methodology, Data synthesis, Writing – Review editing. Chiamaka Judith Ezenwa: Original draft preparation, Literature search, Investigation, Writing - Review editing. Joakin Chidozie Nwaokoro: Original draft preparation, Data Extraction, Investigation, Validation. Uzochukwu Godswill Ekeleme : Validation, Supervision, Study Selection, Interpretation of result, Original draft preparation. Rejoicing Chijindum Innocent : Interpretation of results, Quality assessment, Original draft preparation Final Approval of the Manuscript All authors Acknowledgements Not Applicable References Griffin, J. B., McClure, E. M., Kamath‐Rayne, B. D., Hepler, B. M., Rouse, D. J., Jobe, A. H., & Goldenberg, R. L. (2017). Interventions to reduce neonatal mortality: A mathematical model to evaluate impact of interventions in sub‐Saharan Africa. Acta Paediatrica, 106(8), 1286–1295. Bee, M., Shiroor, A., & Hill, Z. (2018). Neonatal care practices in sub-Saharan Africa: A systematic review of quantitative and qualitative data. Journal of Health, Population and Nutrition, 37, 1–12. Sazawal, S., Dhingra, U., Ali, S. M., Dutta, A., Deb, S., Ame, S. M., Mkasha, M. H., Yadav, A., & Black, R. E. (2016). 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Health care providers’ perspectives regarding the use of chlorhexidine gel for cord care in neonates in rural Kenya: Implications for scale-up. BMC health services research, 17(1), 1-10. Soofi, S., Cousens, S., Imdad, A., Bhutto, N., Ali, N., & Bhutta, Z. A. (2012). Topical application of chlorhexidine to neonatal umbilical cords for prevention of omphalitis and neonatal mortality in a rural district of Pakistan: a community-based, cluster-randomised trial. The Lancet, 379(9820), 1029-1036. Sharma, D., & Gathwala, G. (2014). Impact of chlorhexidine cleansing of the umbilical cord on cord separation time and neonatal mortality in comparison to dry cord care–a nursery-based randomized controlled trial. The Journal of Maternal-Fetal & Neonatal Medicine, 27(12), 1262-1265. El Arifeen, S., Mullany, L. C., Shah, R., Mannan, I., Rahman, S. M., Talukder, M. R. R., ... & Baqui, A. H. (2012). The effect of cord cleansing with chlorhexidine on neonatal mortality in rural Bangladesh: a community-based, cluster-randomised trial. The Lancet, 379(9820), 1022-1028. McClure, E. M., Goldenberg, R. L., Brandes, N., Darmstadt, G. L., Wright, L. L., & CHX Working Group. (2007). The use of chlorhexidine to reduce maternal and neonatal mortality and morbidity in low-resource settings. International Journal of Gynecology & Obstetrics, 97(2), 89-94. Dhingra, U., Sazawal, S., Dhingra, P., Dutta, A., Ali, S. M., Ame, S. M., ... & Black, R. E. (2015). Trial of improved practices approach to explore the acceptability and feasibility of different modes of chlorhexidine application for neonatal cord care in Pemba, Tanzania. BMC pregnancy and childbirth, 15(1), 1-8. Ambale, C., Ngatia, B., & Nthusi, J. (2019). Assessment of Chlorhexidine use for cord care at Kangundo level 4 Hospital Tielsch, J. M., Darmstadt, G. L., Mullany, L. C., Khatry, S. K., Katz, J., LeClerq, S. C., ... & Adhikari, R. (2007). Impact of newborn skin-cleansing with chlorhexidine on neonatal mortality in southern Nepal: a community-based, cluster-randomized trial. Pediatrics, 119(2), e330-e340. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Editor assigned by journal 14 Oct, 2025 Reviews received at journal 25 Aug, 2025 Reviewers agreed at journal 19 Aug, 2025 Reviewers agreed at journal 15 Aug, 2025 Reviewers agreed at journal 13 Aug, 2025 Reviewers invited by journal 11 Aug, 2025 Submission checks completed at journal 10 Jun, 2025 First submitted to journal 09 Jun, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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06:58:28","extension":"xml","order_by":11,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":134500,"visible":true,"origin":"","legend":"","description":"","filename":"7e660bdc3b5f41bf8309d25aad42138b1structuring.xml","url":"https://assets-eu.researchsquare.com/files/rs-4400991/v1/17379f9b78982b390bbc16b2.xml"},{"id":94844941,"identity":"4503a83b-ef7f-452a-a2a0-94876617a9eb","added_by":"auto","created_at":"2025-10-31 10:06:35","extension":"html","order_by":12,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":146779,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-4400991/v1/b2e89af8fe5da9135420ac0e.html"},{"id":94844929,"identity":"5bd2ddc1-c994-419d-9f92-742ce689f09a","added_by":"auto","created_at":"2025-10-31 10:06:34","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":39718,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003ePRISMA Flow Diagram [18], Demonstrating the Study Selection Process\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-4400991/v1/7d83899a43a43bef9a63d803.png"},{"id":94990452,"identity":"542cdff4-c459-4286-8174-65f9008b425d","added_by":"auto","created_at":"2025-11-03 07:17:09","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1625121,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4400991/v1/c35c9462-06ad-41b8-a590-4e5d8c454428.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eA Systematic Review of the Effectiveness of Existing Umbilical Cord Care Interventions in Preventing Omphalitis and Reducing Neonatal Mortality in Sub-saharan Africa\u003c/p\u003e","fulltext":[{"header":"1.0 Introduction","content":"\u003cp\u003eNeonatal mortality is a major public health concern in Sub-Saharan Africa (SSA) than other parts of the world [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. According to recent data, Sub-Saharan Africa is responsible for a disproportionate amount of global newborn fatalities, with around 29 deaths per 1,000 live births [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Griffin et al. [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e] provided statistics of approximately 3\u0026nbsp;million neonates deaths occurring annually, with 98% occurring in low-and-middle-income countries (LMIC) and neonatal infections and contributes to approximately 15\u0026ndash;20% of neonatal sepsis cases in resource-limited settings, primarily in Sub-Saharan Africa and Asia.\u003c/p\u003e\u003cp\u003eUmbilical cord care is very important for neonatal well-being, most especially in preventing omphalitis, this is an infection occurring on the umbilical cord stump possibly causing major complications and even death if not taken care of [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. In SSA, where access to healthcare resources is typically limited and traditional practices prevail, proper umbilical cord care is necessary to minimise the risk of newborn infections and improve survival rates [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Irrespective of the availability of diverse therapies and practices for umbilical cord care, their efficacy in preventing omphalitis and lowering neonatal mortality in SSA needs more exploration [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eSeveral challenges are faced in safeguarding the health and well-being of newborns in SSA. This continually contributes to the increase in neonatal mortality rates [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. There is limited access to reliable healthcare services, most especially in rural and remote locations, posing significant obstacles to timely and effective neonatal treatment [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Furthermore, the cultural views and traditional practices on labour and newborn care contrast with evidence-based recommendations, leading to inefficient and ineffective care as poverty, inadequate nutrition, and a lack of education worsen the predicament the women and newborns face in this region [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eUmbilical cord care methods and approaches vary in Sub-Saharan Africa, from indigenous traditions to modern healthcare procedures [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Traditional techniques includes but not limited to the application of herbs, ash, or animal dung on the umbilical stump, increasing the risk of infection [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. However, evidence-based interventions, employs the utilization of hygienic measures such as keeping the cord clean and dry, as well as the use of antiseptics such chlorhexidine [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Several programmes and initiatives promote these practices, these programmes include activities such as community health worker training, community-based education campaigns, and the incorporation of umbilical cord care into maternity and child health services [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e\u003cdiv id=\"Sec2\" class=\"Section2\"\u003e\u003ch2\u003e1.1 Rationale\u003c/h2\u003e\u003cp\u003eDespite the importance of umbilical cord care in neonatal health, significant gaps in the understanding of the effectiveness of current therapies exist, particularly in the prevention of omphalitis and their role in lowering neonatal mortality rates in SSA. Systematic reviews have been conducted to generate evidence for interventions to reduce neonatal mortality in Sub-Saharan Africa[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e], Topical umbilical cord care for prevention of infection and neonatal mortalities [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e], Umbilical cord-care practices in low-and middle-income countries [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e], however, there are existing reviews but this study is necessary to bridge the knowledge gap. However, addressing these research gaps is critical for developing evidence-based policies and treatments to improve neonatal health outcomes and reduce infant mortality in Sub-Saharan Africa.\u003c/p\u003e\u003cp\u003eThus, this study aims to assess the effectiveness of existing umbilical cord care strategies in preventing omphalitis and lowering neonatal mortality rates in the region.\u003c/p\u003e\u003cp\u003eSystemic review question should be stated here\u003c/p\u003e\u003c/div\u003e"},{"header":"2.0 Methods","content":"\u003cp\u003e\u003cstrong\u003e2.1 Eligibility criteria\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe eligibility criteria for this review were developed using the PEO framework [16]. These criteria serve to determine the scope of the evaluation by identifying the characteristics of the research that will be included and eliminated. Table 1.0 shows the study\u0026apos;s eligibility requirements.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1.0 Eligibility Criteria\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"666\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 180px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCriteria\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 221px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eInclusion\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 265px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eExclusion\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 180px;\"\u003e\n \u003cp\u003ePopulation (P)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 221px;\"\u003e\n \u003cp\u003eNeonates, Pregnant women, Mothers and healthcare providers in Sub-Saharan Africa,\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 265px;\"\u003e\n \u003cp\u003eNeonates with congenital abnormalities, Neonates with known immunodeficiency disorders\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 180px;\"\u003e\n \u003cp\u003eExposure (E)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 221px;\"\u003e\n \u003cp\u003eExisting umbilical cord care interventions\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 265px;\"\u003e\n \u003cp\u003eStudies not focused on umbilical cord care\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 180px;\"\u003e\n \u003cp\u003eOutcome (O)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 221px;\"\u003e\n \u003cp\u003eIncidence of omphalitis, Neonatal mortality rates\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 265px;\"\u003e\n \u003cp\u003eStudies without data on omphalitis, and/or neonatal mortality rates\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 180px;\"\u003e\n \u003cp\u003eStudy Design\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 221px;\"\u003e\n \u003cp\u003eRandomized controlled trials (RCTs), Quasi-experimental studies, - Observational studies (cohort, case-control, Cross-sectional), - Qualitative studies\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 265px;\"\u003e\n \u003cp\u003eSystematic reviews and meta-analyses\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 180px;\"\u003e\n \u003cp\u003eLanguage\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 221px;\"\u003e\n \u003cp\u003eEnglish\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 265px;\"\u003e\n \u003cp\u003eStudies published in languages other than English\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 180px;\"\u003e\n \u003cp\u003eStudy Duration\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 221px;\"\u003e\n \u003cp\u003eStudies published between 2014 - 2024\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 265px;\"\u003e\n \u003cp\u003eStudies published before 2014\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003ePublication type\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 221px;\"\u003e\n \u003cp\u003eOriginal peer reviewed Articles\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 265px;\"\u003e\n \u003cp\u003e- Preprints, short communications, and consensus reports. - Non-original articles (e.g., review articles, meta-analyses).\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003e2.2 Information Sources\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTo discover relevant studies for this systematic review, we used a comprehensive search technique. The databases that were searched include PubMed, European PMC, and Google Scholar. Additional papers were identified by hand-searching the reference lists of the included studies, as well as relevant review articles. The search was undertaken until February 24, 2024, ensuring that the most recent evidence was included in the review.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2.3 Search Strategy\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis review search strategy\u0026nbsp;was created utilising Medical Subject Headings [MESH], synonyms, and free text terms\u0026nbsp;to standardise, increase precision, and assure comprehensive retrieval of relevant literature [17]. The search was made in the following databases:\u003c/p\u003e\n\u003cp\u003e\u0026bull; PubMED\u003c/p\u003e\n\u003cp\u003e\u0026bull;European PMC\u003c/p\u003e\n\u003cp\u003e\u0026bull; Google scholar\u003c/p\u003e\n\u003cp\u003eA search was further conducted on the reference list of selected potential research. Boolean operators (OR, AND, NOT), brackets, truncations, proximities, and wildcards were used to combine or exclude search terms, enabling more accurate and thorough retrieval of relevant material from databases by defining links between search terms and improving search results. Table 2.0 outlines the study\u0026apos;s detailed search strategy.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2.0 Search Strategy\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"630\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 42px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eS/N\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePrimary Keyword\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eBoolean Operators (Joining Type)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 276px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMESH Terms/Synonyms/Free Text terms\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNumber of Hits\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 42px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003eUmbilical cord care interventions\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e\u0026ldquo;OR\u0026rdquo;, \u0026ldquo;(\u0026hellip;.)\u0026rdquo;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 276px;\"\u003e\n \u003cp\u003e((\u0026ldquo;Umbilical Cord\u0026rdquo;) OR (\u0026ldquo;Cord Care\u0026rdquo;) OR (Umbilicus\u0026rdquo;) OR (\u0026ldquo;Neonatal Care\u0026rdquo;) OR (\u0026ldquo;Infection Control\u0026rdquo;) OR (Antiseptics) OR (Sterilization) OR (Hygiene) OR (\u0026ldquo;Health Education\u0026rdquo;) OR (\u0026ldquo;Traditional Medicine\u0026rdquo;) OR (\u0026ldquo;Medical Practices\u0026rdquo;) OR (\u0026ldquo;Health Promotion\u0026rdquo;) OR (\u0026ldquo;Maternal-Child Health Services\u0026rdquo;) OR (\u0026ldquo;Neonatal Nursing\u0026rdquo;))\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e412,493\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 42px;\"\u003e\n \u003cp\u003eN/A\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e\u0026nbsp;-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003eAND\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 276px;\"\u003e\n \u003cp\u003eAND\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003eN/A\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 42px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003eOmphalitis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e\u0026ldquo;OR\u0026rdquo;, \u0026ldquo;(\u0026hellip;.)\u0026rdquo;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 276px;\"\u003e\n \u003cp\u003e((Omphalitis) OR (\u0026ldquo;Umbilical Cord Infections\u0026rdquo;) OR (\u0026ldquo;Umbilical Infections\u0026rdquo;) OR (\u0026ldquo;Neonatal Sepsis\u0026rdquo;) OR (\u0026ldquo;Bacterial Infections and Mycoses\u0026rdquo;) OR (\u0026ldquo;Enterobacteriaceae Infections\u0026rdquo;) OR (\u0026ldquo;Streptococcal Infections\u0026rdquo;) OR (\u0026ldquo;Staphylococcal Infections\u0026rdquo;) OR (Sepsis) OR (\u0026ldquo;Infection Control\u0026rdquo;) OR (\u0026ldquo;Antibiotic Therapy\u0026rdquo;) OR (\u0026ldquo;Wound Infection\u0026rdquo;) OR (Inflammation) OR (\u0026ldquo;Neonatal Nursing\u0026rdquo;))\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e93,492\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 42px;\"\u003e\n \u003cp\u003eN/A\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e\u0026nbsp;-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003eAND\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 276px;\"\u003e\n \u003cp\u003eAND\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003eN/A\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 42px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003eNeonatal Mortality\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e\u0026ldquo;OR\u0026rdquo;, \u0026ldquo;(\u0026hellip;.)\u0026rdquo;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 276px;\"\u003e\n \u003cp\u003e((\u0026ldquo;Neonatal Mortality\u0026rdquo;) OR (\u0026ldquo;Infant Mortality\u0026rdquo;) OR (\u0026ldquo;Perinatal Mortality\u0026rdquo;) OR (\u0026ldquo;Newborn Mortality\u0026rdquo;) OR (\u0026ldquo;Infant Death\u0026rdquo;) OR (Stillbirth) OR (Birth Outcome) OR (\u0026ldquo;Cause of Death\u0026rdquo;) OR (\u0026ldquo;Mortality Risk Factors\u0026rdquo;) OR (\u0026ldquo;Epidemiology, Infant Mortality\u0026rdquo;) OR (\u0026ldquo;Maternal Health\u0026rdquo;) OR (\u0026ldquo;Prenatal Care\u0026rdquo;))\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e748,292\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 42px;\"\u003e\n \u003cp\u003eN/A\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e\u0026nbsp;-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003eAND\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 276px;\"\u003e\n \u003cp\u003eAND\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003eN/A\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 42px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003eSub-Sharan Africa\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e\u0026ldquo;OR\u0026rdquo;, \u0026ldquo;(\u0026hellip;.)\u0026rdquo;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 276px;\"\u003e\n \u003cp\u003e((Sub-Saharan Africa) \u0026nbsp;OR (Benin) OR (Botswana) OR (Burkina Faso) OR (Ghana) OR (Guinea) OR (Guinea-Bissau) OR (Kenya) OR (Malawi) OR (Mali) OR (Namibia) OR (Niger) OR (Nigeria) OR (Rwanda) OR (Senegal) OR (Sierra Leone) OR (South Africa) OR (South Sudan) OR (Sudan) OR (Tanzania) OR (Togo) OR (Uganda) OR (Zambia) OR (Zimbabwe))\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e1,283,372\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 42px;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 504px;\"\u003e\n \u003col\u003e\n \u003cli\u003eAND (2) AND (3) AND (4)\u003c/li\u003e\n \u003c/ol\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e1,309\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003e2.4 Study Selection\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe Zotero reference software was utilised to de-duplicate the studies. Studies were initially selected\u0026nbsp;based on the titles and abstracts. Following that, full-text screening was used to further\u0026nbsp;exclude studies that did not meet the inclusion criteria. This screening was carried out independently by PEA, DCI and RCI to pre-defined inclusion criteria leading to the retrieval of 8 studies [3, 8, 22, 23, 24, 25]. The criteria for excluding studies were noted on the PRISMA flow diagram [18].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2.5 Data Items\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMicrosoft Excel was used to extract pertinent data from chosen studies. The following information was extracted: study characteristics (e.g., study design, sample size, duration), participant demographics (e.g., age, gender), intervention details (e.g., type of umbilical cord care intervention, duration, frequency), desired outcomes (e.g., incidence of omphalitis, neonatal mortality rates). These items were summarised in text and shown in a table 4.0\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2.6 Study Risk of Bias Assessment\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe Critical Appraisal Skills Programme (CASP) instruments are used to examine the methodological quality and validity of the review [19]. The quality assessment was carried out independently by DCI, PEA and RCI. CASP offers a systematic approach to evaluating research, considering criteria such as study design, sample size, data collection methods, and statistical analysis [19, 20]. The CASP checklist assesses the quality of the included studies under the following domain: Was the study question or objective clearly stated?; Was the study design appropriate for the research question?; Was the sample size justified and adequate?; Were the study participants clearly described?; Were the measurements clearly defined and reliable?; Were confounding factors considered in the design and analysis?; Were the statistical methods appropriate?; Were the results clearly presented?; Was the discussion and interpretation of results appropriate?. This method aids in the identification of potential biases and limits that may have an impact on the study\u0026apos;s reliability and generalizability. The use of CASP guarantees that the included studies are of high quality, offering substantial evidence to inform conclusions and recommendations about the effectiveness of umbilical cord care treatments in preventing omphalitis and reducing neonatal mortality in sub-Saharan Africa.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2.7 Data Synthesis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe review\u0026apos;s data synthesis, which employs narrative synthesis, entails collecting and summarising qualitative findings from individual studies [21]. This method comprises detecting common themes, patterns, and linkages among research on the efficacy of umbilical cord care interventions in preventing omphalitis and lowering infant mortality in Sub-Saharan Africa. The review uses narrative synthesis to explore parallels and differences in study outcomes, intervention strategies, and contextual factors that may influence efficacy. Furthermore, the narrative synthesis may investigate the level of evidence, consistency of findings, and potential sources of heterogeneity or bias among the included research. By narratively synthesising data, the study gives a complete and nuanced knowledge of the available evidence base, providing insights into the overall impact of umbilical cord care interventions on infant health outcomes in the area.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2.8 Reporting Bias Assessment\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis review employed a technique to evaluate the risk of bias stemming from missing results, encompassing reporting biases. This approach entailed completing a thorough search strategy across numerous databases and sources to discover relevant studies, reducing the possibility of selective reporting bias. The review used this strategy to reduce the influence of reporting biases while increasing the reliability and validity of the synthesised data.\u003c/p\u003e"},{"header":"3.0 Results","content":"\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\u003ch2\u003e3.1 Overview of Search Process\u003c/h2\u003e\u003cp\u003eA search through electronic databases such as PubMED, European PMC, and Google scholar yielded a total of 1309 studies. Following record de-duplication and study screening, 658 studies were eligible for full text screening, and studies were excluded based on the predetermined eligibility criteria leaving six (6) studies which met the review\u0026rsquo;s inclusion criteria. Figure\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e depicts the PRISMA flow chart, which shows the study selection process and reasons for exclusion of studies.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e\u003ch2\u003e3.2 Characteristics of Included Studies\u003c/h2\u003e\u003cp\u003eThis review included a total of six studies. One study was conducted in Kenya, two studies were carried out in Zambia, one in Nigeria, one study in Tanzania, and one in South Sudan. Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3.0\u003c/span\u003e illustrates the characteristics of the included studies.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3.0\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eCharacteristics of Included Studies\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"8\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eS/N\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eStudy Author and Date\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eStudy Aim or Title\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eSample Size and Participant Characteristics\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eStudy Design and Methodology\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003eIntervention Details\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003eOutcome of Interest\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c8\"\u003e\u003cp\u003eStudy Setting\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e1.\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSazawal et al. (2016)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eEfficacy of chlorhexidine application to umbilical cord on neonatal mortality in Pemba, Tanzania: a community-based randomised controlled trial\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e36,911 newborn babies enrolled, aged 1 hour to 48 hours, without congenital malformations.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eCommunity-based randomized controlled trial on Pemba Island, Zanzibar, Tanzania.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e4% chlorhexidine solution applied to the umbilical cord daily until 3 days after the cord had dropped off.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eNeonatal mortality rates, incidence of omphalitis\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003ePemba Island, Zanzibar, Tanzania\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e2.\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSemrau et al. (2016)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eEffectiveness of 4% chlorhexidine umbilical cord care on neonatal mortality in Southern Province, Zambia (ZamCAT): a cluster-randomised controlled trial\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e42,356 pregnant women screened, 39,679 women enrolled, with 37,856 live births.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eCluster-randomized controlled trial in Southern Province, Zambia.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eTopical application of 10 mL of a 4% chlorhexidine solution once per day until 3 days after cord drop.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eNeonatal mortality rates\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eSouthern Province, Zambia\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e3.\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePark et al. (2021)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eComponents of clean delivery kits and newborn mortality in the Zambia Chlorhexidine Application Trial (ZamCAT): An observational study\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eData from the Zambia Chlorhexidine Application Trial (ZamCAT).\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eObservational study using data from the ZamCAT.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eClean delivery kits containing soap, gloves, cord clamps, plastic sheet, razor blade, matches, and candle provided to all pregnant women.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eNeonatal mortality rates\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eZambia\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e4.\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eDraiko et al. (2021)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eThe effect of umbilical cord cleansing with chlorhexidine gel on neonatal mortality among the community births in South Sudan: a quasi-experimental study\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e3,143 pregnant women recruited from six rural communities in Jubek County, South Sudan.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003ePre/post quasi-experimental study conducted in Jubek County, South Sudan.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eChlorhexidine applied to umbilical cord stump within 24 hours of birth and daily for seven days.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eNeonatal mortality rates\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eJubek County, South Sudan\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e5.\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eOkoye et al. (2022)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eA Cross Sectional Comparative Study of Methylated Spirit and Chlorhexidine in Preventing Neonatal Cord Infections in a Local Hospital, Jos-Plateau State, Nigeria\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e20 mother-baby pairs in methylated spirit group, 14 mother-baby pairs in chlorhexidine group. Jos, Nigeria.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eCross-sectional comparative study conducted in a local hospital in Jos, Nigeria.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eComparison of methylated spirit and chlorhexidine in preventing omphalitis, neonatal sepsis, and neonatal mortality.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eIncidence of omphalitis, neonatal sepsis, neonatal mortality rates\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eJos-Plateau State, Nigeria\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e6.\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMuriuki et al. (2017)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eHealth care providers\u0026rsquo; perspectives regarding the use of chlorhexidine gel for cord care in neonates in rural Kenya: Implications for scale-up\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eIn-depth interviews with 39 service providers from 21 facilities in Bungoma County, Kenya.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eQualitative study exploring health care providers' perspectives in Bungoma County, Kenya.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003ePerspectives of health care providers regarding the use of 7.1% Chlorhexidine Digluconate (CHX) gel for newborn umbilical\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eAcceptability of chlorhexidine gel use and implications for scale-up.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eBungoma County, Kenya\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec15\" class=\"Section2\"\u003e\u003ch2\u003e3.3 Quality assessment of Included Studies\u003c/h2\u003e\u003cp\u003eFor assessing the quality of the studies included in the synthesis of this review, the Critical Appraisal Skilled Programme (CASP) checklist was used. Studies were appraised using the yes, no, and not clear in each domain. \u0026ldquo;Yes\u0026rdquo; was awarded 1 point, \u0026ldquo;No\u0026rdquo; was given 0, while \u0026ldquo;Not clear\u0026rdquo; was given 0.5 Studies that scored 8\u0026ndash;9 were graded \u0026ldquo;High\u0026rdquo; Studies that scored 1\u0026ndash;4 were graded \u0026ldquo;Low\u0026rdquo;, while studies scoring 5\u0026ndash;7 were graded \u0026ldquo;Medium\u0026rdquo;. Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4.0\u003c/span\u003e below illustrates the quality assessment of the studies included in this review.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 4.0\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eQuality assessment of Included studies\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"12\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c11\" colnum=\"11\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c12\" colnum=\"12\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eS/N\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eStudy Author\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eWas the study question or objective clearly stated?\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eWas the study design appropriate for the research question?\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eWas the sample size justified and adequate?\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003eWere the study participants clearly described?\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003eWere the measurements clearly defined and reliable?\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c8\"\u003e\u003cp\u003eWere confounding factors considered in the design and analysis?\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c9\"\u003e\u003cp\u003eWere the statistical methods appropriate?\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c10\"\u003e\u003cp\u003eWere the results clearly presented?\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c11\"\u003e\u003cp\u003eWas the discussion and interpretation of results appropriate?\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c12\"\u003e\u003cp\u003eOverall Assessment\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e1.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSazawal et al. [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u003cp\u003e9/9 (High)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e2.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSemrau et al. [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u003cp\u003e9/9 (High)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e3.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePark et al. [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u003cp\u003e9/9 (High)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e4.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eDraiko et al. [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u003cp\u003e9/9 (High)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e5.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eOkoye et al. [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u003cp\u003e9/9 (High)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e6.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMuriuki et al. [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u003cp\u003e9/9 (High)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec16\" class=\"Section2\"\u003e\u003ch2\u003e3.4 Result of Synthesis\u003c/h2\u003e\u003cdiv id=\"Sec17\" class=\"Section3\"\u003e\u003ch2\u003e3.4.1 Risk of Bias among Contributing Studies\u003c/h2\u003e\u003cp\u003eThe synthesis of the included studies indicates a wide variety of characteristics and various levels of bias among the contributing studies. Studies on the effectiveness of umbilical cord care interventions in lowering infant mortality in Sub-Saharan Africa included a variety of geographical areas, populations, intervention methodologies, and research designs. Some trials used stringent randomised controlled designs with large sample sizes and extended follow-up periods, while others used quasi-experimental or observational methods. Variability in intervention methods, outcome assessments, and control group treatments all contributed to the overall variability among trials. Risk of bias assessments revealed varying levels of methodological quality, with some studies displaying strong procedures and low bias, while others had problems such as small sample sizes, insufficient blinding, or incomplete outcome reporting. Despite these differences, combining the findings from multiple studies provides useful insights into the overall effectiveness and feasibility of umbilical cord care interventions in lowering newborn mortality in Sub-Saharan Africa.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec18\" class=\"Section3\"\u003e\u003ch2\u003e3.4.2 Findings\u003c/h2\u003e\u003cp\u003eThis study shed light on eight main findings: effectiveness of chlorhexidine application; comparison of different cord care interventions; impact on omphalitis incidence; adherence and implementation challenges; maternal and neonatal health outcomes; health equity and accessibility; cost-effectiveness and scalability; casualty and association with mortality.\u003c/p\u003e\u003cdiv id=\"Sec19\" class=\"Section4\"\u003e\u003ch2\u003e3.4.2.1 Effectiveness of Chlorhexidine Application\u003c/h2\u003e\u003cp\u003eFour included studies, [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e], showcased the usefulness of chlorhexidine treatment as a crucial intervention in preventing omphalitis and lowering newborn mortality in SSA. Sazawal et al. [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e] conducted a randomised controlled trial which focused on the effects of a 4% chlorhexidine solution on infant mortality in Tanzania. The study found no significant difference in mortality rates in the chlorhexidine groups. However, this study provides vital information in the African context. Similarly, Semrau et al. [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e] conducted a cluster-randomised controlled trial to determine the efficacy of 4% chlorhexidine umbilical cord care in lowering infant mortality rates in Zambia. The study did not find a significant difference in mortality in the chlorhexidine groups but contributes to the understanding of this intervention in a Sub-Saharan African setting. Draiko et al. [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e] also conducted a quasi-experimental study in South Sudan, where chlorhexidine gel application to the umbilical cord stump resulted in a significant reduction in cord sepsis and neonatal mortality, highlighting the potential efficacy of chlorhexidine in unsanitary settings. Additionally, Park et al. [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e] conducted a study in Zambia that highlighted the value of clean delivery kits containing chlorhexidine in lowering infant mortality rates, implying a possible pathway for improving outcomes in resource-limited settings. Collectively, these studies add to this review by showcasing the varying significance of chlorhexidine's in improving newborn outcomes and emphasising the need for additional study in SSA.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec20\" class=\"Section4\"\u003e\u003ch2\u003e3.4.2.2 Comparison of Different Cord Care Interventions\u003c/h2\u003e\u003cp\u003eFour included studies discussed the effectiveness of various cord care strategies in preventing omphalitis and lowering infant mortality in Sub-Saharan Africa [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. Sazawal et al. [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e] conducted a community-based randomized controlled trial in Tanzania, comparing 4% chlorhexidine solution to dry cord care. The researchers found no significant difference in infant mortality rates between the chlorhexidine and dry cord care groups. Similarly, Semrau et al. [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e] carried out a cluster-randomized controlled trial in Zambia, comparing chlorhexidine treatment to dry cord care. The researchers discovered no significant difference in infant mortality rates between the two groups. These studies imply that chlorhexidine treatment may not be significantly more effective than dry cord care in lowering newborn mortality in Sub-Saharan Africa. However, Draiko et al. [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e] conducted a quasi-experimental study in South Sudan comparing chlorhexidine administration to dry cord care and discovered that chlorhexidine application dramatically reduced newborn cord infection rates and mortality. Okoye et al. [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e] did a comparative cross-sectional study in Nigeria to determine the effectiveness of chlorhexidine and methylated spirit in reducing newborn cord infections. The study's data indicated no significant difference in the effectiveness of chlorhexidine against methylated spirit in preventing omphalitis, newborn sepsis, and neonatal death. This comparison tells on the alternative therapies that can be utilized in situations where certain cord care agents are unavailable or considered dangerous. Collectively, these studies contribute to a better understanding of the various outcomes related to different cord care interventions in Sub-Saharan Africa, providing useful insights for healthcare practices and policy decisions in the region.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec21\" class=\"Section4\"\u003e\u003ch2\u003e3.4.2.3 Impact on Omphalitis Incidence\u003c/h2\u003e\u003cp\u003eTwo selected studies hit on the key subjects of how umbilical cord care interventions affect omphalitis or cord infections in Sub-Saharan Africa [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. Draiko et al. [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e] conducted a quasi-experimental investigation in South Sudan. The study utilized the application of chlorhexidine gel to the umbilical cord stump and found a statistically significant reduction in neonatal cord infection rates. Conversely, Okoye et al. [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e] did a cross-sectional comparison study in Jos, Nigeria, comparing chlorhexidine with methylated spirit, indicating that there was no significant difference in preventing omphalitis with either treatment. While both studies advance our understanding of cord care strategies, they highlight the need for additional study to determine the most effective and feasible interventions for preventing omphalitis and lowering infant death in Sub-Saharan Africa.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec22\" class=\"Section4\"\u003e\u003ch2\u003e3.4.2.4 Adherence and Implementation Challenges\u003c/h2\u003e\u003cp\u003eRegarding the adherence to and challenges of implementing umbilical cord care interventions, findings emerge from five included studies [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. The views of healthcare providers in rural Kenya on the usage of chlorhexidine gel for newborn umbilical cord care was evaluated by Muriuki in 2017 [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. The study found that healthcare providers approved of the usage of chlorhexidine gel for umbilical cord care and supported its widespread implementation on the recommendation that proper training, community education, and staffing difficulties be addressed to enable successful implementation, highlighting positive provider perceptions. This understanding of healthcare providers' viewpoints is useful for identifying potential barriers to intervention uptake as well as facilitators. Furthermore, Sazawal et al. [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e] and Semrau et al. [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e] conducted trials in Tanzania and Zambia, respectively, highlighting the limitations of delivering interventions at the community level. These studies shed light on the practical obstacles encountered while carrying out umbilical cord care interventions, which are critical for understanding the techniques' real-world applicability and sustainability in a variety of Sub-Saharan African settings. Furthermore, Park et al. [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e] carried out a cluster-randomised controlled trial in Zambia, where chlorhexidine use met obstacles in both urban and rural settings, emphasising the need to overcome implementation barriers for effective intervention. Additionally, Okoye et al. [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e] conducted a study in Nigeria to compare the efficacy of methylated spirit versus chlorhexidine in reducing omphalitis, newborn sepsis, and mortality. While both interventions produced equal results in the first four days of life, the study emphasised the need of considering implementation issues. Okoye et al. [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e] proposed that methylated spirit could be a more practical option, especially in resource-constrained situations where chlorhexidine supply or pricing may be limited. These findings highlight the importance of taking adherence and implementation issues into account when deploying umbilical cord care programmes in Sub-Saharan Africa, ensuring their effectiveness in avoiding omphalitis and lowering infant mortality rates. The synthesis of these studies emphasises not only the importance of community and provider views but also the possible barriers to implementing effective umbilical cord care treatments for infant health in the region.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec23\" class=\"Section4\"\u003e\u003ch2\u003e3.4.2.5 Maternal and Neonatal Health Outcomes\u003c/h2\u003e\u003cp\u003eThe finding on maternal and neonatal health outcomes dominates the synthesis of the included studies for the review with insights from five of the selected studies [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. Semrau et al. [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e] conducted a cluster-randomized controlled study to investigate the effect of 4% chlorhexidine umbilical cord care on infant mortality rates. While there was no significant difference in mortality rates between the chlorhexidine and dry cord care groups, the study provides important insights into the broader context of maternal and newborn health outcomes, particularly considering the importance of neonatal mortality as a major outcome. In a similar vein, Draiko et al. [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e] conducted a quasi-experimental study, finding that chlorhexidine gel treatment helped to reduce cord sepsis and infant death in conflict-affected areas. Additionally, Okoye et al. [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e] conducted a cross-sectional study to compare the efficacy of methylated spirit versus chlorhexidine in reducing newborn cord infections. The study discovered that both medicines produced similar results throughout the first four days of life, with cord separation happening primarily between days 7 and 9. The results show that the two interventions have similar effects on maternal and newborn health outcomes, emphasising the necessity of knowing unique cord care methods and their impact on health outcomes in different settings. These studies, which focus on newborn health outcomes, provide critical information for policymakers and healthcare practitioners in Sub-Saharan Africa looking to optimise treatments and improve maternal and neonatal health in the region.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec24\" class=\"Section4\"\u003e\u003ch2\u003e3.4.2.6 Health Equity and Accessibility\u003c/h2\u003e\u003cp\u003eA critical finding emerges from three included studies during the synthesis of the review highlighting the health equity and accessibility of these interventions [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Muriuki et al. [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e] investigated healthcare practitioners' opinions in rural Kenya, offering light on the problems and potential solutions to implementing cord care interventions in resource-constrained settings. The study emphasised the necessity for scalable and accessible interventions as well as the importance of addressing difficulties such as personnel shortages and community sensitization to provide equitable access to excellent umbilical cord care. Furthermore, Sazawal et al. [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e] conducted a study in Tanzania, emphasising the difficulties of delivering treatments at the community level and the need to ensure access to all segments of the population. This study emphasises the need for accessible and practical interventions in resource-limited settings to address health inequities. Draiko et al. [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e] conducted research in South Sudan, a conflict-torn region with inadequate access to healthcare services. The data showed that using chlorhexidine gel reduced cord sepsis and infant mortality rates, implying that even in difficult settings, implementing effective cord care interventions can improve health equality. The synthesis of these studies emphasises the importance of developing interventions that are not only effective but also accessible in a variety of settings, particularly in regions with limited healthcare resources, to ensure equitable maternal and neonatal health outcomes across Sub-Saharan Africa.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec25\" class=\"Section4\"\u003e\u003ch2\u003e3.4.2.7 Cost-effectiveness and Scalability\u003c/h2\u003e\u003cp\u003eThree included studies highlight the importance of cost-effectiveness and scalability of applied interventions [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Muriuki et al. [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e] in rural Kenya, collected information from healthcare practitioners on the usage of chlorhexidine gel for newborn umbilical cord care. The study emphasised the recognition of achieving scalability for a successful implementation of intervention as it addresses workforce numbers, training, and community sensitization. Draiko et al. [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e] conducted a study in South Sudan that focused on how chlorhexidine gel treatment reduced cord infections and infant mortality rates. While the study does not directly address cost-effectiveness, it emphasises the intervention's potential scalability, particularly in resource-constrained and conflict-affected contexts. Park et al. [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e] conducted a study in Zambia to determine the efficacy of chlorhexidine for dry cord care. Although the study did not show a significant reduction in infant mortality rates, it did provide insights on the viability and scalability of chlorhexidine use in a distinct African context. Collectively, these studies provide useful insights into the cost-effectiveness and scalability of umbilical cord care interventions, emphasising the importance of techniques that are not only beneficial but also viable and sustainable in a variety of locations throughout Sub-Saharan Africa.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec26\" class=\"Section4\"\u003e\u003ch2\u003e3.4.2.8 Causality and Association with Mortality\u003c/h2\u003e\u003cp\u003eFour studies included in this review provide light on the causality and correlation between umbilical cord care interventions and infant mortality in Sub-Saharan Africa [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Sazawal et al. [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e] conducted a randomised controlled experiment in Tanzania to determine the effectiveness of chlorhexidine treatment to the umbilical cord. Although their study found no statistically significant reduction in infant mortality rates, it helps to understand the relationship between chlorhexidine use and mortality outcomes. Similarly, Semrau et al. [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e] conducted a cluster-randomized controlled study in Zambia to compare chlorhexidine with dry cord care and discovered no significant difference in infant mortality rates between the intervention and control groups. However, Park et al. [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e] did an observational study in Zambia to investigate the components of clean delivery kits and their relationship with neonatal death. They discovered that particular kit components, like as gloves and cord clamps, were related with lower infant mortality rates, indicating a possible causal relationship between clean delivery methods and mortality outcomes. Furthermore, Draiko et al. [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e] conducted a quasi-experimental study in South Sudan that showed a reduction in neonatal mortality rates after using chlorhexidine gel, implying a possible link between the intervention and mortality reduction. These studies highlight the significance of additional study to demonstrate causality and explain appropriate umbilical cord care strategies for reducing infant mortality in Sub-Saharan Africa.\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv id=\"Sec27\" class=\"Section3\"\u003e\u003ch2\u003e3.4.3 Summary of Findings/Themes\u003c/h2\u003e\u003cp\u003eThe review of the effectiveness of existing umbilical cord care interventions in preventing omphalitis and lowering neonatal mortality in Sub-Saharan Africa identifies several major trends throughout the included trials. First, studies by Sazawal et al. [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e] and Draiko et al. [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e] showed that chlorhexidine can reduce cord infections and infant mortality rates, especially in resource-limited situations. Second, Semrau et al. [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e] discovered no significant difference in death rates between chlorhexidine and dry cord care, contrary to Draiko et al. [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e] study, emphasising the need for additional study to determine definite efficacy. Third, the impact of these therapies on omphalitis or cord infections, as emphasised by Okoye et al. [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e] highlights the considerable reduction in cord infections linked with chlorhexidine use, indicating its potential to reduce neonatal morbidity. In terms of adherence and implementation challenges, Muriuki et al. [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e] identified staffing levels, training, and community sensitization as critical for the successful scale-up of cord care interventions, emphasising the importance of addressing these barriers in order to ensure widespread adoption. Maternal and newborn health outcomes, as addressed by Park et al. [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e] and Draiko et al. [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e] suggest that while chlorhexidine use shows promise in lowering neonatal death, its effectiveness may vary depending on context and setting. Muriuki et al. [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e] emphasise the importance of providing equitable access to high-quality care, particularly in underserved areas, in order to effectively address health inequities. Furthermore, Muriuki et al. [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e] and Draiko et al. [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e] found that chlorhexidine interventions might be scaled up, particularly in resource-limited situations. However, additional study is required to determine the long-term cost-effectiveness and durability of these therapies. Finally, in terms of causality and mortality rates, studies by Semrau et al. [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e] and Draiko et al. [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e] shed light on the relationship between umbilical cord care interventions, particularly chlorhexidine administration, and neonatal mortality rates. These studies provide evidence for a potential causal association, demonstrating that adequate cord care can help reduce newborn deaths. Overall, while chlorhexidine application shows promise in lowering infant mortality and cord infections, addressing implementation issues and ensuring equitable availability are critical to the successful implementation of umbilical cord care interventions in Sub-Saharan Africa.\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"4.0 Discussion, Implications of Findings, Strengths and Limitations","content":"\u003cdiv id=\"Sec29\" class=\"Section2\"\u003e\u003ch2\u003e4.1 Discussion of Findings\u003c/h2\u003e\u003cp\u003eThe evaluation of how well current umbilical cord care therapies work at preventing omphalitis and lowering infant mortality in Sub-Saharan Africa covers a wide range of important topics found in the studies that were included. To begin, the efficacy of chlorhexidine administration is identified as a critical factor in lowering cord infections and infant mortality rates. Sazawal et al. [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e] and Draiko et al. [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e] found promising results, indicating that chlorhexidine treatment considerably reduces the incidence of omphalitis and leads to decreased infant mortality rates, especially in resource-limited situations. Similarly, Soofi et al. [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e] found that applying 4% chlorhexidine to the umbilical cord reduced the risk of omphalitis and infant mortality. These findings are consistent with previous research from Asia, such as Sharma et al.'s [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e] study in Northern India, which found that using chlorhexidine for umbilical cord care shortens cord separation time and reduces neonatal mortality in a teaching hospital's NICU, indicating that chlorhexidine has the potential to be a cost-effective and accessible intervention for improving newborn health outcomes in Sub-Saharan Africa. While chlorhexidine has shown success in specific situations, its effectiveness may vary based on circumstances such as birth location (home vs. facility), maternal health status, and socioeconomic position. As a result, more studies are needed to better understand the factors that influence success and tailor interventions to the needs of distinct populations.\u003c/p\u003e\u003cp\u003eDraiko et al. [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e] found that chlorhexidine was more effective in preventing omphalitis than dry cord care techniques. While Draiko et al. [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e] indicated that chlorhexidine is effective in preventing cord sepsis and neonatal mortality, Semrau et al. [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e] discovered no significant difference in mortality rates between chlorhexidine and dry cord care. A study conducted in rural Bangladesh by El Arifeen et al. [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e] demonstrated that multiple washings of the cord with chlorhexidine documented a statistically significant reduction in the incidence of serious cord infection. Compared to the dry cord care group. These inconsistent findings highlight the complexities of assessing the efficacy of cord care interventions as well as the need for additional research to understand the comparative effectiveness of various techniques across distinct circumstances. Furthermore, this study emphasises the significance of evidence-based practices in shaping clinical recommendations and policy decisions. Chlorhexidine's ability to effectively reduce cord infections shows that it has the potential to reduce newborn morbidity and mortality, especially in areas with limited access to healthcare resources. However, implementation problems such as supply chain management, healthcare provider training, and community participation must be addressed to ensure chlorhexidine's widespread adoption and maximum impact on neonatal health outcomes.\u003c/p\u003e\u003cp\u003eThe impact of cord care interventions on omphalitis or cord infections, as demonstrated by Okoye et al. [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e], emphasises the need for preventive approaches to lower infant morbidity. These studies show that chlorhexidine use leads to considerable decreases in cord infections, underscoring its importance as a vital intervention in decreasing the incidence of newborn sepsis. Furthermore, the findings imply that chlorhexidine use may help to enhance maternal and newborn health outcomes, which is consistent with global efforts to meet maternity and child health SDG targets.\u003c/p\u003e\u003cp\u003eAccording to McClure et al.\u0026rsquo;s [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e] study, despite promising research, widespread adoption and implementation of chlorhexidine use have yet to occur. Muriuki et al. [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e] highlighted adherence and implementation issues as important impediments to the successful scaling-up of cord care programmes in Sub-Saharan Africa. Their study indicated that staffing shortages, inadequate training, and community views may impede the effective delivery of chlorhexidine and other preventive interventions. In contrast, Dhingra et al. [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e] found that the overall acceptability of CHX treatment for cord washing was high. Their findings imply that knowing the community's attitudes, beliefs, and cultural traditions, as well as selecting the most appropriate manner of CHX distribution, is critical to the design and implementation of intervention trials. Also, Ambale et al. [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e] discovered that at Kangundo Level 4 hospital, both customers and HCWs had a poor understanding of how to use CHX. Addressing these issues necessitates a holistic approach that includes investments in health system strengthening, capacity training, and community involvement initiatives. Furthermore, initiatives to enhance health equity and accessibility are critical for ensuring that vulnerable populations have equal access to high-quality care and preventive interventions.\u003c/p\u003e\u003cp\u003eFinally, the link between cord care interventions and neonatal mortality rates, as demonstrated by Semrau et al. [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e] and Draiko et al. [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e], highlights the potential impact of effective cord care on overall mortality rates. Tielsch et al. [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e] discovered that newborn skin-wiping with a chlorhexidine solution once, immediately after birth, reduced neonatal mortality only in low-birth-weight infants, which is consistent with their findings. While this evidence implies a link between chlorhexidine use and decreased mortality rates, determining causality requires additional research. Confounding variables, study design flaws, and contextual differences all have the potential to influence mortality outcomes and should be carefully explored in future research. In conclusion, the findings of this research emphasise the relevance of evidence-based cord care measures in preventing omphalitis and lowering infant death. The findings of the review highlight the multifaceted character of umbilical cord care interventions and their implications for infant health in Sub-Saharan Africa. While chlorhexidine application appears to be an effective strategy for preventing omphalitis and lowering neonatal mortality, addressing implementation challenges and promoting health equity are critical for maximising intervention impact and improving maternal and child health outcomes in the region.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec30\" class=\"Section2\"\u003e\u003ch2\u003e4.2 Limitations of the Included Evidence\u003c/h2\u003e\u003cp\u003eThe evidence provided in this review has numerous limitations that should be considered. First, the variation in study designs, intervention regimens, and outcome measures among the included studies introduces significant heterogeneity, making direct comparisons difficult. Furthermore, while some studies used rigorous randomised controlled trials (RCTs), others used quasi-experimental designs or observational methodologies, which could have an impact on the evidence's quality and dependability. Inconsistencies in reported outcomes may also be caused by changes in intervention implementation, such as variances in dosage, application methods, and adherence. Some studies also revealed methodological issues, such as poor blinding, incomplete outcome reporting, and attrition bias, which could jeopardise the internal validity of the findings, the included studies' largely rural or unique geographic settings may restrict the generalizability of the results since they may not adequately represent the different people and healthcare situations in Sub-Saharan Africa. Also, relying on available literature could potentially introduce publication bias, as the publication of positive studies may lead to an overestimation of intervention effectiveness. Despite these limitations, these evidence sheds light on the present level of knowledge about umbilical cord care interventions in Sub-Saharan Africa, laying the groundwork for future research and policy action in this vital area of public health.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec31\" class=\"Section2\"\u003e\u003ch2\u003e4.3 Limitations of the Review Process\u003c/h2\u003e\u003cp\u003eThe review processes used to synthesise research on umbilical cord care interventions and infant mortality reduction in Sub-Saharan Africa have their limitations. First, the search strategy used to locate relevant research may have introduced selection bias as other databases or sources were neglected, potentially resulting in the omission of pertinent literature. Furthermore, linguistic constraints in the search technique may result in the exclusion of research published in languages other than those indicated, restricting the breadth of the evidence base. Additionally, the review's inclusion criteria may mistakenly eliminate research that provides useful insights or alternate views, limiting the scope of the synthesis. Also, the quality assessment techniques used to evaluate the included studies may differ in rigour or objectivity, altering the overall interpretation of the evidence. Finally, while the narrative synthesis approach is useful for qualitatively summarising findings, it may lack the statistical power and precision of formal meta-analyses, limiting the strength of the review's conclusions. Recognising these limits is critical for comprehending the potential biases and uncertainties inherent in review processes, as well as correctly assessing synthesised evidence.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec32\" class=\"Section2\"\u003e\u003ch2\u003e4.4 Strengths of the Review\u003c/h2\u003e\u003cp\u003eThis review strengths lies on the fact that it reviewed its data across peer reviewed databases and also it utlised the PRISMA flow diagram which shows the comprehensiveness of the review process. Also the critical appraisal performed in this review provides significant strength to this review process\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec33\" class=\"Section2\"\u003e\u003ch2\u003e4.4 Implication of Findings to Practice\u003c/h2\u003e\u003cp\u003eThe findings of this review have important implications for practice aiming at improving maternal and child health outcomes, especially in Sub-Saharan Africa. To begin, the evidence supporting the efficacy of chlorhexidine treatment in lowering omphalitis and infant mortality rates highlights the need to incorporate this intervention into existing maternal and child health programmes. Chlorhexidine is a simple, low-cost remedy that has the potential to greatly reduce the incidence of newborn infections and mortality, especially in resource-constrained situations where access to healthcare services is limited. However, addressing implementation problems such as providing proper healthcare provider training, encouraging community engagement, and improving supply chain management is critical for maximising the benefit of chlorhexidine application programmes. Furthermore, measures to promote health equity and reduce inequities in access to care are crucial to ensuring that vulnerable groups benefit from these initiatives. Collaboration among governments, healthcare professionals, community organisations, and international partners is required to scale up successful cord care programmes, enhance health systems, and ultimately improve mother and child health outcomes in Sub-Saharan Africa.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec34\" class=\"Section2\"\u003e\u003ch2\u003e4.5 Implications of the Findings to Policy.\u003c/h2\u003e\u003cp\u003eThe findings of this review have major implications for policy creation and implementation in maternal and child health. To begin, the evidence supporting the efficacy of chlorhexidine application in lowering omphalitis and infant mortality rates suggests that policymakers prioritise the incorporation of this intervention into national and regional health policies and recommendations. Incorporating chlorhexidine into routine umbilical cord care practices can help ensure that this life-saving measure is available consistently and widely across healthcare facilities and communities. Furthermore, policy efforts to scale up effective cord care treatments should prioritise tackling implementation problems such as training healthcare practitioners, ensuring the availability of chlorhexidine supplies, and increasing community awareness and acceptance. Policymakers should also examine initiatives to enhance health equity and eliminate inequities in access to care, especially among marginalised and underserved communities. This could include targeted initiatives like community outreach programmes, mobile health clinics, and subsidies for vital healthcare goods to ensure that all mothers and babies have access to high-quality cord care services. Overall, incorporating evidence-based interventions such as chlorhexidine application into health policies and initiatives can help to reduce newborn mortality and advance progress towards mother and child health targets at the national and international levels.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec35\" class=\"Section2\"\u003e\u003ch2\u003e4.6 Implications of the Findings to Future Research.\u003c/h2\u003e\u003cp\u003eThe findings of this review have numerous implications for future research, emphasising the importance of ongoing exploration and innovation in the field of mother and child health. First, while existing studies provide valuable insights into the efficacy of chlorhexidine application and other cord care interventions, more research is needed to improve our understanding of the optimal implementation strategies, such as dosage, timing, and frequency of application, as well as the comparative effectiveness of different interventions in various settings. Furthermore, future research should prioritise rigorous evaluation methods, such as large-scale randomised controlled trials and longitudinal studies, to generate strong evidence on the long-term impact of cord care interventions on neonatal health outcomes, such as mortality rates and omphalitis prevalence. Furthermore, given the dynamic nature of healthcare systems and developing issues, such as new pathogens and shifting sociodemographic patterns, continued research is required to identify novel ways and technologies for enhancing cord care practices and overcoming implementation difficulties. Collaborative research initiatives between academic institutions, government agencies, non-governmental organisations, and community stakeholders will be critical for expanding the evidence base and improving maternal and child health policies and practices.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec36\" class=\"Section2\"\u003e\u003ch2\u003e4.7 Conclusion\u003c/h2\u003e\u003cp\u003eFinally, this systematic review gives a thorough summary of the efficacy, implementation issues, and consequences of current umbilical cord care initiatives in Sub-Saharan Africa. The review emphasises the possibility of chlorhexidine application and other cord care therapies in preventing omphalitis and lowering infant mortality rates by synthesizing evidence from multiple studies. However, the review reveals knowledge and implementation problems, such as challenges with adherence, scalability, and health inequalities. Moving forward, policymakers, healthcare professionals, researchers, and community stakeholders must work together to ensure the effective and fair administration of cord care interventions in a variety of settings. Future research and policy initiatives can significantly improve maternal and child health outcomes in Sub-Saharan Africa by building on existing evidence's strengths and addressing its limitations, ultimately contributing to the broader global agenda of reducing neonatal mortality and advancing universal health coverage.\u003c/p\u003e\u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics Approval and Consent to Participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eN/A\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for Publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors have given their consent to the publication of this review.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of Data and Materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData would be made available on request, by the corresponding author.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting Interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAuthors have declared that they have no competing interests\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo funds were received for this study\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors Contribution\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors that contributed to the review process have been acknowledged with their permission.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePrecious Ebube Anyakorah\u003c/strong\u003e: Conceptualization, Protocol development, Original draft preparation, Project co-ordination, Methodology, Data synthesis, Study selection, and Writing - Review editing.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDavid Chinaecherem Innocent\u003c/strong\u003e: Supervision, Original draft preparation, Literature search, Quality assessment, Methodology, Study selection, Data Extraction, Writing - Review editing.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eChidinma Peace Ahunam\u003c/strong\u003e: Original draft preparation, Quality assessment, Methodology, Data synthesis, Writing – Review editing.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eChiamaka Judith Ezenwa:\u0026nbsp;\u003c/strong\u003eOriginal draft preparation, Literature search, Investigation, Writing - Review editing.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eJoakin Chidozie Nwaokoro:\u0026nbsp;\u003c/strong\u003eOriginal draft preparation, Data Extraction, Investigation, Validation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eUzochukwu Godswill Ekeleme\u003c/strong\u003e: Validation, Supervision, Study Selection, Interpretation of result, Original draft preparation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eRejoicing Chijindum Innocent\u003c/strong\u003e: Interpretation of results, Quality assessment, Original draft preparation\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFinal Approval of the Manuscript\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot Applicable\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eGriffin, J. 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Umbilical Cord Hygiene And The Risk Of Neonatal Sepsis Among Neonates Presenting At Kahawa Health Centre In Nairobi County, Kenya.\u003c/li\u003e\n\u003cli\u003eIshaq, M., Noor, B., Ahad, A., Muhammad, N., \u0026amp; Bibi, R. (2023). Chlorhexidine for the Prevention of Omphalitis in neonates with a single dose. Pakistan Journal of Medical \u0026amp; Health Sciences, 17(04), 141\u0026ndash;141.\u003c/li\u003e\n\u003cli\u003eNankabirwa, V., Tyllesk\u0026auml;r, T., Tumuhamye, J., Tumwine, J. K., Ndeezi, G., Martines, J. C., \u0026amp; Sommerfelt, H. (2017). Efficacy of umbilical cord cleansing with a single application of 4% chlorhexidine for the prevention of newborn infections in Uganda: Study protocol for a randomized controlled trial. Trials, 18(1), 1\u0026ndash;9.\u003c/li\u003e\n\u003cli\u003eShukla, V. V., \u0026amp; Carlo, W. A. (2020). Review of the evidence for interventions to reduce perinatal mortality in low-and middle-income countries. International Journal of Pediatrics and Adolescent Medicine, 7(1), 4\u0026ndash;10.\u003c/li\u003e\n\u003cli\u003eKarumbi, J., Mulaku, M., Aluvaala, J., English, M., \u0026amp; Opiyo, N. (2013). Topical umbilical cord care for prevention of infection and neonatal mortality. The Pediatric Infectious Disease Journal, 32(1), 78.\u003c/li\u003e\n\u003cli\u003eLefebvre, C., Glanville, J., Briscoe, S., Littlewood, A., Marshall, C., Metzendorf, M. I., ... \u0026amp; Cochrane Information Retrieval Methods Group. (2019). Searching for and selecting studies. Cochrane Handbook for systematic reviews of interventions, 67-107.\u003c/li\u003e\n\u003cli\u003eRichter, R. R., \u0026amp; Austin, T. M. (2012). Using MeSH (medical subject headings) to enhance PubMed search strategies for evidence-based practice in physical therapy. Physical Therapy, 92(1), 124\u0026ndash;132.\u003c/li\u003e\n\u003cli\u003ePage, M. J., McKenzie, J. E., Bossuyt, P. M., Boutron, I., Hoffmann, T. C., Mulrow, C. D., Shamseer, L., Tetzlaff, J. M., Akl, E. A., \u0026amp; Brennan, S. E. (2021). The PRISMA 2020 statement: An updated guideline for reporting systematic reviews. International Journal of Surgery, 88, 105906.\u003c/li\u003e\n\u003cli\u003eSingh, J. (2013). Critical appraisal skills programme. Journal of pharmacology and Pharmacotherapeutics, 4(1), 76-76.\u003c/li\u003e\n\u003cli\u003eQuigley, J. M., Thompson, J. C., Halfpenny, N. J., \u0026amp; Scott, D. A. (2019). Critical appraisal of nonrandomized studies\u0026mdash;A review of recommended and commonly used tools. Journal of Evaluation in Clinical Practice, 25(1), 44\u0026ndash;52.\u003c/li\u003e\n\u003cli\u003eLisy, K., \u0026amp; Porritt, K. (2016). Narrative synthesis: Considerations and challenges. JBI Evidence Implementation, 14(4), 201.\u003c/li\u003e\n\u003cli\u003eSemrau, K. E., Herlihy, J., Grogan, C., Musokotwane, K., Yeboah-Antwi, K., Mbewe, R., ... \u0026amp; Hamer, D. H. (2016). Effectiveness of 4% chlorhexidine umbilical cord care on neonatal mortality in Southern Province, Zambia (ZamCAT): a cluster-randomised controlled trial. The Lancet Global Health, 4(11), e827-e836.\u003c/li\u003e\n\u003cli\u003ePark, J. H., Hamer, D. H., Mbewe, R., Scott, N. A., Herlihy, J. M., Yeboah-Antwi, K., \u0026amp; Semrau, K. E. (2021). Components of clean delivery kits and newborn mortality in the Zambia Chlorhexidine Application Trial (ZamCAT): An observational study. PLoS Medicine, 18(5), e1003610.\u003c/li\u003e\n\u003cli\u003eOkoye, C. F., Okoh, E. E., Ager, T., Ikpeama, O. J., Ogbodo, I. J., Aguyi, I., ... \u0026amp; Kingsley, A. P. (2022). A Cross Sectional Comparative Study of Methylated Spirit and Chlorhexidine in Preventing Neonatal Cord Infections in a Local Hospital, Jos-Plateau State, Nigeria. Tropical Journal of Medical Research, 21(2), 85-92.\u003c/li\u003e\n\u003cli\u003eMuriuki, A., Obare, F., Ayieko, B., Matanda, D., Sisimwo, K., \u0026amp; Mdawida, B. (2017). Health care providers\u0026rsquo; perspectives regarding the use of chlorhexidine gel for cord care in neonates in rural Kenya: Implications for scale-up. BMC health services research, 17(1), 1-10.\u003c/li\u003e\n\u003cli\u003eSoofi, S., Cousens, S., Imdad, A., Bhutto, N., Ali, N., \u0026amp; Bhutta, Z. A. (2012). Topical application of chlorhexidine to neonatal umbilical cords for prevention of omphalitis and neonatal mortality in a rural district of Pakistan: a community-based, cluster-randomised trial. The Lancet, 379(9820), 1029-1036.\u003c/li\u003e\n\u003cli\u003eSharma, D., \u0026amp; Gathwala, G. (2014). Impact of chlorhexidine cleansing of the umbilical cord on cord separation time and neonatal mortality in comparison to dry cord care\u0026ndash;a nursery-based randomized controlled trial. The Journal of Maternal-Fetal \u0026amp; Neonatal Medicine, 27(12), 1262-1265.\u003c/li\u003e\n\u003cli\u003eEl Arifeen, S., Mullany, L. C., Shah, R., Mannan, I., Rahman, S. M., Talukder, M. R. R., ... \u0026amp; Baqui, A. H. (2012). The effect of cord cleansing with chlorhexidine on neonatal mortality in rural Bangladesh: a community-based, cluster-randomised trial. The Lancet, 379(9820), 1022-1028.\u003c/li\u003e\n\u003cli\u003eMcClure, E. M., Goldenberg, R. L., Brandes, N., Darmstadt, G. L., Wright, L. L., \u0026amp; CHX Working Group. (2007). The use of chlorhexidine to reduce maternal and neonatal mortality and morbidity in low-resource settings. International Journal of Gynecology \u0026amp; Obstetrics, 97(2), 89-94.\u003c/li\u003e\n\u003cli\u003eDhingra, U., Sazawal, S., Dhingra, P., Dutta, A., Ali, S. M., Ame, S. M., ... \u0026amp; Black, R. E. (2015). Trial of improved practices approach to explore the acceptability and feasibility of different modes of chlorhexidine application for neonatal cord care in Pemba, Tanzania. BMC pregnancy and childbirth, 15(1), 1-8.\u003c/li\u003e\n\u003cli\u003eAmbale, C., Ngatia, B., \u0026amp; Nthusi, J. (2019). Assessment of Chlorhexidine use for cord care at Kangundo level 4 Hospital\u003c/li\u003e\n\u003cli\u003eTielsch, J. M., Darmstadt, G. L., Mullany, L. C., Khatry, S. K., Katz, J., LeClerq, S. C., ... \u0026amp; Adhikari, R. (2007). Impact of newborn skin-cleansing with chlorhexidine on neonatal mortality in southern Nepal: a community-based, cluster-randomized trial. Pediatrics, 119(2), e330-e340.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-pediatrics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bped","sideBox":"Learn more about [BMC Pediatrics](http://bmcpediatr.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bped/default.aspx","title":"BMC Pediatrics","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Umbilical Cord Care, Omphalitis, Neonatal Mortality, Sub-Saharan Africa, Chlorhexidine, Systematic Review","lastPublishedDoi":"10.21203/rs.3.rs-4400991/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4400991/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNeonatal mortality remains a major public health concern in Sub-Saharan Africa, with umbilical cord infections accounting for a substantial proportion of these deaths. This systematic review seeks to synthesise existing evidence on the effectiveness of existing umbilical cord care strategies in preventing omphalitis and lowering infant mortality Sub-Saharan Africa using a narrative approach.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e1309 studies were identified through a thorough search of electronic databases such as PubMed, European PMC, and Google Scholar between 2014 and 2024. Studies were screened according to predetermined inclusion and exclusion criteria. Data was extracted using Microsoft Excel, In addition, the quality of the selected studies was assessed using the CASP checklist. Due to the heterogeneity of the selected studies the synthesis of data synthesis was performed using narrative synthesis\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe review includes six papers, including randomised controlled trials, observational research, and qualitative investigations. The included trials covered a wide range of therapies, such as chlorhexidine application, dry cord care, alcohol application, and clean birth kits. The combined findings demonstrate the efficacy of chlorhexidine treatment in lowering omphalitis incidence and neonatal mortality rates. Comparative assessments of various cord care methods reveal variable effects on infant health outcomes. Implementation obstacles, such as adherence issues and healthcare system barriers, were observed in multiple studies. In addition, the review looked into the relationship between cord care interventions and maternal and newborn health outcomes, health equity, accessibility, cost-effectiveness, scalability, causality, and mortality rates.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis systematic review sheds light on the current evidence basis for umbilical cord care interventions in Sub-Saharan Africa. Despite differences in study techniques and outcomes, the review emphasises the need to tackle newborn mortality and omphalitis through focused interventions and health-system strengthening initiatives. Future research should focus on overcoming implementation barriers, improving health equity and accessibility, and assessing the long-term impact and scalability of cord care interventions in various contexts across the area.\u003c/p\u003e\n\u003cp\u003eManuscript PROSPERO registration number [CRD42024540612]\u003c/p\u003e","manuscriptTitle":"A Systematic Review of the Effectiveness of Existing Umbilical Cord Care Interventions in Preventing Omphalitis and Reducing Neonatal Mortality in Sub-saharan Africa","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-10-31 10:06:30","doi":"10.21203/rs.3.rs-4400991/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorAssigned","content":"","date":"2025-10-14T10:38:41+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-08-25T11:40:48+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"304266906331490876333191122859469537048","date":"2025-08-19T21:06:20+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"33442760656003421025439257205027827113","date":"2025-08-15T08:53:56+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"311093272034385827117890558148654563433","date":"2025-08-13T11:18:17+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-08-11T08:18:41+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-06-10T10:45:33+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Pediatrics","date":"2025-06-09T13:28:40+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-pediatrics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bped","sideBox":"Learn more about [BMC Pediatrics](http://bmcpediatr.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bped/default.aspx","title":"BMC Pediatrics","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"fc1a8015-b16c-4e47-81d4-5c35ea66d451","owner":[],"postedDate":"October 31st, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-10-31T10:06:30+00:00","versionOfRecord":[],"versionCreatedAt":"2025-10-31 10:06:30","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4400991","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4400991","identity":"rs-4400991","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}