A Report of At-Scale Distribution of Chlorhexidine Digluconate 7.1% Gel for Newborn Cord Care to 36,404 Newborns in Sokoto State, Nigeria: Initial Lessons Learned

BACKGROUND With an annual estimated 276,000 neonatal deaths, Nigeria has the second highest of any country in the world. Global progress in accelerating neonatal deaths is hinged to scaled-up interventions in Nigeria. We used routine data of chlorhexidine digluconate 7.1% gel utilized by 36,404 newborns delivered by 36,370 mothers, to study lessons associated with at-scale distribution in Sokoto State, North West Nigeria. METHODS AND FINDINGS Under state government leadership, a community-based distribution system overseen by 244 ward development committees and over 3,440 community-based health volunteers and community drug keepers, was activated to deliver two locally stored medicines to women when labor commenced. Newborns and their mothers were tracked through 28 days and 42 days respectively, including verbal autopsy results. 36,404 or 26.3% of expected newborns received the gel from April 2013 to December 2013 throughout all 244 wards in the State. 99.97% of newborns survived past 28 days. There were 124 pre-verified neonatal deaths reported. Upon verification using verbal autopsy procedures, 76 deaths were stillborn and 48 were previously live births. Among the previous 48 live births, the main causes of death were sepsis (40%), asphyxia (29%) and prematurity (8%). Underuse of logistics management information by government in procurement decisions and not accounting for differences in LGA population sizes during commodity distribution, severely limited program scalability. CONCLUSIONS Enhancements in the predictable availability and supply of chlorhexidine digluconate 7.1% gel to communities through better, evidence-based logistics management by the state public sector will most likely dramatically increase program scalability. Infections as a cause of mortality in babies delivered in home settings may be much higher than previously conceived. In tandem with high prevalence of stillborn deaths, delivery, interventions designed to increase mothers' timely and regular use of quality antenatal care, and increased facility-based based delivery, need urgent attention. We call for accelerated investments in community health volunteer programs and the requisite community measurement systems to better track coverage. We also advocate for the development, refinement and use of routine community-based verbal autopsies to track newborn and maternal survival.