The first 28 days of life represent the most vulnerable period for a newborn, characterized by significant physiological transitions and high risk of morbidity and mortality. Globally, an estimated 2.3 million neonates died in 2022, translating to nearly 6,400 deaths everyday (1). According to United Nations Children’s Fund (UNICEF) 2021 neonatal mortality (NM) report, sub-Saharan Africa accounted for over 1.2 million neonatal deaths annually, with an average neonatal mortality rate (NMR) of 27 deaths per 1000 live births (1, 2). In Uganda, NMR remains high, at 22 per 1,000 live births, contributing to 42% of all under-five deaths (3).

The majority of deaths in Uganda are attributed to preventable causes including sepsis, tetanus, diarrhea, prematurity, and birth asphyxia (4). Among these, neonatal sepsis, often linked to inadequate umbilical cord care, accounts for approximately 15% of neonatal deaths (5, 6). Furthermore, suboptimal umbilical cord care related sepsis is implicated in approximately 700,000 neonatal deaths per year globally (7, 8, 9). Although institutional delivery and antenatal care attendance have increased in the past decades from 36% in 2001 to 86% in 2022 and 93% in 2001 to 99% in 2022 respectively, it does not resonate with NM reduction trends, for reasons related to little or no marked improvement in community based newborn care practices including umbilical cord care (3, 10).

Evidence based recommendations for umbilical cord care varies by setting. In high resource environments, dry cord care is advised, while in low resource settings or where home births are more prevalent, 4 % chlohexidine solution or gel is the recommended standard (11, 12), and other substances other than 4% chlorhexidine solution or gel are regarded non-recommended. Despite strong evidence supporting it’s use, including demonstrated reduction in NM in south Asia and other regions, adherence to these guidelines remains suboptimal in many low and middle income countries (13, 14, 15).

More efforts have been exerted to improve neonatal outcomes including post natal care checks within 24 hours, on day 3 and between 7-14 days, and the more recent recommendation of up to 8 ANC visits to increase contact of mothers with skilled providers (12). However, in Uganda and similar settings, studies have shown widespread use of non-recommended substances such as cow ghee, breast milk, Vaseline, ash, cooking oil, and traditional herbal mixtures for umbilical cord care, that have been associated with neonatal sepsis (8, 16).

This was revealed in one study in western Uganda where 70% of mothers used harmful substances that resulted in cord infections (9). Contributing factors included; maternal age, primiparity and home delivery. Similar patterns have been observed in Ethiopia and elsewhere, where cultural practices drive the use of these substances under the belief that they promote healing, and prevent infections and/or bleeding and hasten cord drying (8, 17).

The use of non-recommended substances is closely associated with poverty, low or no education, young motherhood, home birth deliveries, limited access to healthcare, reliance to traditional birth attendants (TBAs) and lack of antenatal care (ANC) attendance (7, 8, 9, 16, 18). Structural and systemic constraints such as low ANC coverage, delayed clinical guidelines updates, inadequate postnatal care attendance, and inconsistent availability of chlorhexidine further exacerbate the problem (3, 8, 9, 12, 19, 20, 21).

The World Health Organization (WHO) emphasizes hygienic cord care as a core component of essential newborn care, recognizing it’s role in reducing neonatal infections and mortality (22). However, in many low and middle income countries including Uganda, uptake remains limited due cultural beliefs, misinformation, socio-demographic factors, and health system constraints (17, 23).

Suboptimal umbilical cord care remains a critical contributor to neonatal sepsis and preventable neonatal mortality in Uganda (9, 24), especially among families from the lower socio-economic backgrounds, which often lack access to skilled birth attendants, clean delivery and living environments, and essential newborn care supplies, factors that increase the reliance on harmful practices including use of non-recommended substances for cord care exposing newborns to otherwise preventable infections (25, 26). This inequity exposes the most vulnerable neonates to life threatening infections, significantly undermining national efforts to reduce newborn deaths.

While the United Nations (UN) has set a global target of reducing NM to fewer than 12 deaths per 1,000 live births by 2030 under the Sustainable Development Goal (SDG) 3, subtheme 3.2, Uganda’s national target is to reduce neonatal deaths from 27 per 1000 live births to 19 per 1000 live births by 2025 (27, 28). Although some progress has been made, with a neonatal mortality declining from 27/1000 live births in 2011 to 22 in 2022 (3), this remains insufficient. Uganda would need to move faster by accelerating it’s rate of reduction to approximately 2 deaths per 1000 live birth per year to remain on truck for the global 2030 agenda. This slow progress reflects persistent gaps in equitable access to quality maternal and newborn care, especially among disadvantaged populations (29). Without targeted community level interventions to eliminate harmful practices like poor umbilical cord care, these gains risk stalling.

Failure to urgently address NM, including deaths resulting from suboptimal cord care poses a significant threat to Uganda’s ability to achieve it’s national and global child survival targets. Neonatal deaths currently account for approximately 61% of all infant deaths and 42% of under-five mortality (3, 27), making it the leading cause of child mortality in the country. If unaddressed, these preventable deaths are likely to undermine Uganda’s efforts to reduce projected infant mortality from 41 to 34 per 1,000 live births, and under-five mortality rate from 62.2 to 30 per 1,000 live births by 2025 (27).

Beyond the immediate human cost, persistently high neonatal and child mortality rates have broader implications for Uganda’s life expectancy, which remains lower than the global average (3, 30). Because these deaths occur early in life, they disproportionally reduce national life expectancy at birth, distorting long term health indicators and masking progress in other population segments (30, 31, 32). Moreover, frequent early childhood deaths represents a direct loss of future human capital and productivity, thereby weakening the labor force, slowing economic growth, and straining health and social systems (33).

Although the 2022 Uganda Essential Maternal and Newborn Clinical Care Guidelines (EMNCC) address newborn health, including infection prevention, they fall short of explicitly recommending the use of 4% chlorhexidine solution or gel for umbilical cord care (12, 34). Additionally, the guidelines lack consistent messages on cord care during critical periods such as antenatal and postnatal care visits, where maternal education on newborn health is most impactful. This noted silence in these guidelines is presumed to stem, in part from lack of nationally representative data on prevalence and partners of using non-recommended substances for cord care in Uganda.

Therefore, this study aims to fill the evidence gap by determining the prevalence of non-recommended cord care practices, identifying the specific substances used, and exploring factors associated with their use among women aged 15-45 years in Uganda. Addressing NM through low-cost interventions such as recommended umbilical cord care is thus not only a public health priority but also a strategic investment in Uganda’s human development and long term prosperity.