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Original Studies

Improving Hygiene in Home Deliveries in Rural Ghana

How to Build on Current Attitudes and Practices

Hill, Zelee PhD*; Tawiah-Agyemang, Charlotte MSc; Okeyere, Eunice BSc; Manu, Alexander MSc; Fenty, Justin MSc; Kirkwood, Betty MSc

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The Pediatric Infectious Disease Journal: November 2010 - Volume 29 - Issue 11 - p 1004-1008
doi: 10.1097/INF.0b013e3181f5ddb1
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Infections are associated with 36% of the neonatal deaths in developing countries.1 Clean delivery (clean hands, clean delivery surface, clean cord cutting and tying, and dry cord care) is a key intervention for reducing infection-related neonatal mortality,2,3 and the promotion of home care practices to prevent newborn infections is a priority research area.4 Despite a recognition of the importance of clean delivery, the mortality effect of individual clean delivery behaviors is unknown. For example, it is recommended that cord ties be sterile because they are in contact with the mucous membrane,5 but there are no studies examining the impact of using sterilized cord ties compared with a new thread, the later being more feasible for home deliveries. Similarly, robust data on hand-washing are lacking. A recent observational study suggests that birth attendant hand-washing could reduce the risk of neonatal death by 25%,6 but intervention trials that encourage hand-washing are needed to verify this finding.

Improving clean home delivery has been a component of several community-based newborn intervention trials. These intervention trials have been implemented mainly in Asia through home visits by community health workers, participatory women's groups, and through training traditional birth attendants (TBAs), and all have shown changes in clean delivery practices such as improved hand-washing, increased use of clean delivery kits, and improved cord care.7–13 Most of these trials were designed based on an understanding of local practices and beliefs.11,14,15 Although such an understanding is recognized as key for designing culturally appropriate community newborn care interventions,16,17 most information about home delivery practices comes from Asia.6,18–27 Practices related to clean delivery in Africa may differ significantly from practices in Asia, but there are few qualitative or quantitative data to verify this.28–30

This article provides data on clean delivery in rural Ghana with the aim of identifying practices that are amenable to change and should be prioritized in community-based interventions, and to determine factors that influence behaviors. The qualitative data were collected as part of the formative research during the planning of a cluster randomized trial implemented at scale. This trial aims to evaluate the impact of a feasible and sustainable home visit intervention (Newhints) on neonatal mortality.31,32


The study collected data from 6 districts in the Brong Ahafo region of Ghana. The districts cover 12,000 square miles and have a predominantly rural population of 600,000 people. Farming is the main activity and more than 60% of households have no electricity supply and 42% of women have no formal education. Most villages are served by dirt roads. At the time of the formative research, 50% of births occurred at home and the current government scheme to provide free facility delivery care was not yet fully operational in the study area. The neonatal mortality rate in the study area was 30 deaths per 1000 live births.

The study collected quantitative data to determine prevalence of clean delivery behaviors and qualitative data understand why behaviors were being practices and whether behavior change was likely. The quantitative data were collected from Newhints control areas during the implementation of this trial through a demographic surveillance system. Data correspond to all women who delivered in the study area between April 2008 and May 2009 and include information on delivery surface, birth attendant hand-washing, and cord care (N = 9167). Detailed information on the surveillance system is presented elsewhere.33 Frequency distributions were determined using Stata 8.0 (Stata Corporation, College Station, TX).

Qualitative data were collected between December 2006 and January 2007 from 14 villages selected to reflect the study area diversity. The methods are described in detail elsewhere.31 A wide range of respondents were selected to give a broad understanding of the barriers and facilitators of behavior change and to understand who influences the behaviors. Quantitative data on cord cutting and tying had been collected through the surveillance system for several years before the collection of the qualitative data. This quantitative data showed that cord cutting and tying were being adequately performed, they were thus not explored in the qualitative data collection.

In total 25 birth narratives with women who had delivered in the last 2 months were conducted, these focused on determining what happened during delivery and what influenced key practices. Thirty in-depth interviews (IDIs) and 2 focus group discussions (FGDs) with women who delivered in the last year or who were pregnant were conducted, these focused on whether current behaviors were amenable to change. Twenty IDIs and 6 FGDs with birth attendants/grandmothers were conducted, these focused on current practices and whether behavior change was likely. Twelve IDIs and 2 FGDs with husbands were conducted, these focused on how husbands are involved in decision-making around essential newborn care and their perceptions of practices. Narrative and IDIs collected information on personal experiences and beliefs and FGDs collected information that required more discussion.

Data were collected in the local language and the sample size for the interviews was determined using saturation sampling; that is respondents were interviewed until no new information was learnt. Women for the birth narratives were selected from the surveillance system and respondents for the in-depth and FGDs through word of mouth. All sampling was purposive to ensure that respondents had a range of ages, ethnicities, parities, education, and socioeconomic status. During the interviews fieldworkers took field notes, which they converted into detailed English transcripts, the same day. A subsample of interviews were tape recorded for data assurance purposes. All FGDs were recorded and then translated and transcribed into English.

The qualitative analysis was conducted by the principle author. The transcripts were explored through multiple readings. Key analytical categories were identified, and the data were systematically indexed using NUD*IST 6 (QSR International) and interpreted. Because some interviews were tape recorded and others captured through note taking, quotes in the results section of this articles are sometimes in the first person (tape recorded) and sometimes in the third person (taken from fieldworker notes).


The prevalence of clean delivery behaviors among those who delivered at home is shown in Table 1. A high prevalence (79%–98%) of appropriate behaviors was found for all clean delivery behaviors except for dry cord care (8%). Most umbilical stumps had either hospital medicine (spirit) (31%) or Shea butter (47%) (a solid oil product extracted from the nuts of the shea tree) applied. The qualitative data confirmed the high prevalence of good practices.

Clean Delivery Behaviors (N = 2631 Home Births)

Delivery Surface

Qualitative data from delivered/pregnant women and birth attendants indicated that not only were women delivered on a covered surface but that this surface was either a new or washed mat/cloth; preparing the delivery surface during pregnancy was normal. Narrative respondents reported that that they cleaned the room in preparation for delivery.

“She scrubbed the room with a sponge and soap a week before delivery because she knew that she was going to deliver in the room and kept mopping the floor each morning” (33-year-old, recently delivered, Bono ethnicity).

All of the respondent groups gave many advantages of a clean and covered delivery surface and the focus group respondents reached consensus on its importance.

“Delivery is on a new or washed mat or rubber or on washed rags,… it is done by all since the baby that is coming is clean so they have to welcome it with a clean thing” (100-year-old, Bono TBA).

“You have to make sure the place is clean enough in order not to bring about any problem … if the place is not clean the child could have an illness like ‘asensene’ [Tetanus]” (20-year-old, Bono, husband).

“She could not imagine anyone being asked to do this [deliver on a clean mat/cloth] without the request being considered an insult as they already understand the importance of this” (60-year-old, Dagarti, TBA).

Other themes related to the delivery surface that emerged from the narratives were having a soft place for the baby to fall onto, the ease of cleaning rubber/plastic after the birth, and the need for a covered surface as the baby would get cold if placed on the floor. Many of the women, grandmothers, and TBAs interviewed had very strong feelings about women who delivered on the bare floor:

“Nobody will put their precious thing [new baby] on the floor” (33-year-old, recently delivered Dagarti).

A theme that emerged from the narratives and was confirmed in the FGDs with women and the birth attendants as a reason for delivering on the bare floor or on an uncleaned surface was a precipitous delivery, however, when this happened respondents complained about the surface:

“She delivered on the bare floor…… she was not happy with the place because it was not clean … there may be some germs on the floor which may enter the baby's body” (23-year-old, recently deliver Fanti).

Impromptu deliveries often were related to late disclosure of labor due to a desire to keep the labor a secret for fear of witchcraft making labor difficult, the social desirability to bear labor pain stoically, and because a long/difficult delivery can signify bad moral behavior of the woman.

The small number of women in the birth narratives who reported that they planned to deliver on the bare floor did so because they considered the room to be already clean, rather than eschewing cleanliness:

“A place that I have swept, why won't it be clean?” (27-year-old, recently delivered Konkomba).

Birth Attendant Hand-washing

Birth attendants in both the IDIs and FGDs reported washing their hands because “the baby should be welcomed with clean hands” (60-year-old, Frafra grandmother), “to prevent infection” (100-year-old, Bono TBA), or to “prevent dirt from touching the skin of the baby” (55-year-old, Bono grandmother).

Themes around not hand-washing included the rush to attend to the woman, not being provided with soap by the family, forgetfulness, and a belief among some that the baby is dirty when born.

“She can wash her hands only if delivery delays, but where the woman is suffering and the baby is coming out she needs to help instantly, so hand washing can't be done” (45-year-old, Dagarti TBA).

“When she is invited to assist with a delivery she abandons whatever she is doing and rushes to the scene. Under such circumstances one can forget to wash hands and can infect the baby in the process” (47-year-old, Bono TBA).

Birth attendants did not report wearing gloves or inserting their hands into the vagina to check on the progression of labor unless there was a problem during delivery.

The birth attendants who did not wash their hands did not think behavior change would be difficult.

“She admitted that she only washes her hands after delivery and not before, this is because she did not know that it was necessary … however she will not have any difficulty practicing the new behavior” (60-year-old Farran TBA).

“Soap is not difficult to come by and is always available in the house” (27-year-old, pregnant Sisala).

Dry Cord Care

The quantitative data show that “doctor medicine” was applied to 31% and Shea butter to 47% of umbilici. The narratives, IDIs, and FGDs with recently delivered and pregnant women suggested that the doctor medicine is usually alcohol and that the Shea butter was usually bought from the market and applied by melting it and using a feather or cotton. The reported frequency of the application varied between every 30 minutes to 3 times a day, but there was a general consensus that the stump should not be allowed to become “dry.” Respondents from all groups universally reported that they either dripped hot water on the stump or applied a hot damp towel to help “heal the sore.” In the first days of life these activities can be done by an experienced female family member or the mother herself.

Women in the narrative, FGDs, and IDIs said that the aim of applying things to the cord was to make the cord soft and come off easily/quickly and to help the sore heal quickly. The sore in the stump is believed to extend into the child's body, and respondents reported that the outside sore should be kept open/wet to allow access to the inside sore:

“The shea butter helps the surface of the sore to be wet so that it won't close up …. If it closes up it will look like it is healed but there will be some sore inside the cord” (40-year-old, recently delivered Mother).

When asked about illnesses that affect newborns the birth attendants and recently delivered/pregnant women described a stump with puss, saying that this was caused by not applying enough hot water to the stump. All respondent groups believed that applying nothing to the cord would have several negative consequences including delaying the cord falling off, discomfort for baby and mother, and potential death for the baby:

“If it is not done the baby cannot sleep well and there will be sickness in his stomach … the sore would go into the stomach and this could kill” (27-year-old, pregnant Sisala).

Questions about whether people in the community could change their behavior, discussed in the FGDs and IDIs, and not put anything on the stump were often met with disbelief:

“When asked if they would change she expressed surprise, and said that at this stage [age] I [the interviewer] should be aware that all wounds should be treated before they can heal” (55-year-old, Bono grandmother).

“Eh! Do you want to kill us … if we don't drip the water how can the sore heal” (40-year-old, recently delivered mother).

“Leave it [stump] dry like that? Impossible …. the practice being suggested is not even carried out at the hospital and so can't help” (60-year-old, Farran TBA).


The current policy in Ghana aims to increase the number of women who deliver in facilities; this is a key strategy to improve clean delivery. For the women who continue to deliver at home, the large number who delivered onto a covered surface (79%) is encouraging, especially as the qualitative data suggest that these are new or washed mats/cloths. Whether washed old cloths and mats should be considered as a clean delivery surface is unclear as inappropriate washing, drying, and storage may lead to contamination. In general women and birth attendants in this part of rural Ghana understand the importance of a clean delivery surface for the health of the baby and do not cover the surface for ease of cleaning as has been observed in some Asian settings.25 Beliefs about the birth as polluting has been identified as a barrier to clean delivery20,27 but do not appear to exist in Ghana, nor do women appear to avoid preparing for a clean delivery for fear of embarrassment as has been reported in some settings.20

Use of a new razor to cut the cord (98%) and a new thread to tie the cord (90%) was higher than levels observed in other studies.7,9,11,18,21–23 Studies have found large variations in cord cutting between districts21 and levels may be lower in other parts of Ghana. Barriers to using a new blade to cut the cord, such as poor availability24 and low knowledge of their importance,25 are not issues in this area of Ghana. The difference between using a sterile versus a new thread/razor is unknown.

The recent observational study suggesting that, in a setting with 30% low birth weight babies, birth attendant hand-washing could reduce the risk of neonatal death by 25%,6 has raised interest in this behavior. The prevalence of birth attendant hand-washing was high (79%) and attendants did not report frequent insertion of hands into the vagina, these findings are in contrast to findings from other settings.18,20–22,24,28,30

Barriers to hand-washing were consistent with those found in Asian studies and included being in a hurry,26 the belief that washing is only important after delivery,20,26 and lack of knowledge that hand-washing protects the child against illness.20 Respondents assumed that behavior change was feasible. A belief that birth is polluting was not found in this area of Ghana. This belief has been identified as making behavior change difficult in other settings.26

The high prevalence of desired behaviors is surprising. In contexts such as this in which some newborn behaviors are being carried out adequately, interventions should focus on other issues. For example, in this setting thermal care and breast-feeding behaviors are not optimal.34,35

Dry cord care was only performed by 8% of families and the qualitative data revealed a deep-rooted belief that the current practice is essential for the baby's health. Putting highly contaminated substances on the cord such as dung was uncommon, however, evidence from Nepal suggests that mustard oil is associated with more cord infections than other substances,36 possibly because it increases percutaneous penetration of pathogens.37 It is unknown if Shea butter has similar properties and this warrants further investigation.

The World Health Organization5 recommends dry cord care unless harmful practices are prevalent, in which case they recommend replacing the harmful practice with a topical antiseptic. There is a possibility of significant resistance to dry cord care in this part of Ghana, and promoting the use of a topical antiseptic may be acceptable and beneficial if Shea butter is harmful. Chlorhexidine has been identified as a safe, inexpensive, and simple antiseptic38 and its daily application to the cord stump reduced neonatal mortality by 24% in a recent randomized control trial in Nepal.39 Trials are needed in African settings, but this promising intervention may offer an acceptable and beneficial alternative to applying Shea butter and other substances to the cord. Chlorhexidine increases the time to cord separation by 24 hours compared with dry care40; this may be problematic in the Ghanaian context where time to cord separation is of great concern.

This study adds to the limited data on newborn care in Africa, but has several limitations. First, respondents may have told interviewers about what they thought, they wanted to hear, and overexaggerated good behaviors; however, the agreement between the different respondent groups and between the quantitative and qualitative data is encouraging. Although recall periods were short, women may not have observed the birth attendant's hand-washing and quantitative data on this are of unknown reliability.41 Wide district variation in newborn behaviors has been found in other studies,21 and the results of this study may not be generalizable to areas in Ghana. However, the data are important in adding the paucity of African data and to inform the design of community interventions such as Newhints.31

Selecting the behaviors that would be the focus of community interventions is difficult, especially where data on the link between the behavior and mortality and morbidity are unclear. In many cases, researchers and program managers have to make a best guess using the available evidence. In the Ghanaian context several behaviors are being performed adequately and should not be the focus of intervention. Other behaviors such as improved cord care should be encouraged, with the knowledge that interventions encouraging the use of chlorhexidine may have more rapid behavior change results than interventions to encourage dry cord care.


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newborn; clean delivery; home visits; hand washing; Ghana

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