***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
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    Input: Background Every year four million babies die in the first month of life and a quarter of these take place in India . A package of essential newborn care practice s exists , which has a proven impact on reducing mortality , and can be implemented in low re source setting s. However , childbirth and the neonatal period are culturally important times , during which there is strong adherence to traditional practice s. Successful implementation of the package therefore requires in-depth knowledge of the local context and tailored behaviour change communication . Methods This study was carried out in rural Karnataka , India . It uses quantitative data from a prospect i ve survey following mothers through their experience of pregnancy and the postnatal period ; and qualitative data from in depth interviews and focus group discussion s conducted with mothers , gr and mothers and birth attendants . It explores local newborn care practice s and beliefs , analyses their harmful or beneficial characteristics and eluci date s areas of potential resistance to behaviour change and implementation of the essential newborn care package . Results Findings show that many potentially harmful newborn care practice s are being carried out in the study area , such as unhygienic cord cutting , delayed breastfeeding and early bathing . Some are more amenable to change than others , depending on the strength of the underlying beliefs , and acceptability of alternative care . However , movement away from traditional practice s is already taking place , particularly amongst the more educated and better off , and there is a clear opportunity to broaden , direct and accelerate this process . Conclusion Community education should be a focus of the National Rural Health Mission ( NRHM ) and Integrated Management of Neonatal and Childhood Illness ( IMNCI ) program being implemented in Karnataka . The added capacity of the new Accredited Social Health Activists ( ASHAs ) could enable more women to be reached . With careful tailoring of behaviour change messages to the local context , government outreach workers can become effective brokers of positive change and significant improvements in home newborn care and neonatal mortality are possible BACKGROUND In low-income countries , including the east African region , a third of neonatal deaths are due to infections . A substantial proportion of these have been attributed to sepsis , which can result from umbilical cord infections . Evidence from Asia suggests that chlorhexidine application to the neonatal umbilical cord reduces mortality , but no data from Africa are available . We aim ed to assess the effect of umbilical cord cleansing with 4 % chlorhexidine solution on neonatal mortality and omphalitis in rural setting s of sub-Saharan Africa . METHODS We did a community-based r and omised controlled trial on Pemba Isl and , Zanzibar , Tanzania . All eligible babies ( aged 1 h to 48 h , without congenital malformations ) from hospital-based and community-based deliveries on Pemba Isl and were enrolled . Participants were r and omly assigned to either 4 % free chlorhexidine for cord care or to dry cord care using a computer-generated r and om sequence . For babies allocated to the chlorhexidine group , mothers or caretakers were advised to apply the solution to the cord every day until 3 days after the cord had dropped off . Cord stumps were examined for redness , pus , swelling , and foul odour on day 0 , 1 , 4 , 10 , and 28 . The primary outcome for this study was mortality until day 28 on an intention-to-treat basis . The trial is registered with Clinical Trials.gov , number NCT01528852 . FINDINGS Between May 19 , 2011 , and Aug 31 , 2014 , 36 911 newborn babies were enrolled into the chlorhexidine ( n=18 015 ) and dry cord care study ( n=18 896 ) groups . 17 468 ( 96·9 % ) of 18 015 neonates in the chlorhexidine group were available for complete follow-up ( 28 days ) compared with 18 384 ( 97·3 % ) of 18 896 neonates in the dry cord care group . Mortality rate in the chlorhexidine group ( 10·5 deaths per 1000 livebirths ) was not significantly lower than that in the dry cord care group ( 11·7 per 1000 livebirths ; relative risk 0·90 , 0·74 - 1·09 ; p=0·27 ) . INTERPRETATION Our findings do not support the use of chlorhexidine for reduction of neonatal mortality in this east African setting , which might not justify a change in the WHO policy . To inform global policy , a detailed meta- analysis and pooled analysis needs to be undertaken using data from both African and Asian setting s. FUNDING Bill & Melinda Gates Foundation BACKGROUND Chlorhexidine umbilical cord washes reduce neonatal mortality in south Asian population s with high neonatal mortality rates and predominantly home-based deliveries . No data exist for sub-Saharan African population s with lower neonatal mortality rates or mostly facility-based deliveries . We compared the effect of chlorhexidine with dry cord care on neonatal mortality rates in Zambia . METHODS We undertook a cluster-r and omised controlled trial in Southern Province , Zambia , with 90 health facility-based clusters . We enrolled women who were in their second or third trimester of pregnancy , aged at least 15 years , and who would remain in the catchment area for follow-up of 28 days post-partum . Newborn babies received clean dry cord care ( control ) or topical application of 10 mL of a 4 % chlorhexidine solution once per day until 3 days after cord drop ( intervention ) , according to cluster assignment . We used stratified , restricted r and omisation to divide clusters into urban or two rural groups ( located < 40 km or ≥40 km to referral facility ) , and r and omly assigned clusters ( 1:1 ) to use intervention ( n=45 ) or control treatment ( n=45 ) . Sites , participants , and field monitors were aware of their study assignment . The primary outcomes were all-cause neonatal mortality within 28 days post-partum and all-cause neonatal mortality within 28 days post-partum among babies who survived the first 24 h of life . Analysis was by intention to treat . Neonatal mortality rate was compared with generalised estimating equations . This study is registered at Clinical Trials.gov ( NCT01241318 ) . FINDINGS From Feb 15 , 2011 , to Jan 30 , 2013 , we screened 42 356 pregnant women and enrolled 39 679 women ( mean 436·2 per cluster [ SD 65·3 ] ) , who had 37 856 livebirths and 723 stillbirths ; 63·8 % of deliveries were facility-based . Of livebirths , 18 450 ( 99·7 % ) newborn babies in the chlorhexidine group and 19 308 ( 99·8 % ) newborn babies in the dry cord care group were followed up to day 28 or death . 16 660 ( 90·0 % ) infants in the chlorhexidine group had chlorhexidine applied within 24 h of birth . We found no significant difference in neonatal mortality rate between the chlorhexidine group ( 15·2 deaths per 1000 livebirths ) and the dry cord care group ( 13·6 deaths per 1000 livebirths ; risk ratio [ RR ] 1·12 , 95 % CI 0·88 - 1·44 ) . Eliminating day 0 deaths yielded similar findings ( RR 1·12 , 95 % CI 0·86 - 1·47 ) . INTERPRETATION Despite substantial reductions previously reported in south Asia , chlorhexidine cord applications did not significantly reduce neonatal mortality rates in Zambia  . Chlorhexidine cord applications do not seem to provide clear benefits for newborn babies in setting s with predominantly facility-based deliveries and lower ( < 30 deaths per 1000 livebirths ) neonatal mortality rates . FUNDING Bill & Melinda Gates Foundation The potential for  traditional birth attendants ( TBAs )  to improve  neonatal health outcomes has largely been overlooked during the current debate regarding the role of TBAs in improving maternal health . R and omly-selected TBAs ( n=93 ) were interviewed to gain a more thorough underst and ing of their knowledge , attitudes , and practice s regarding maternal and newborn care . Practice s , such as using a  clean cord-cutting instrument  ( 89 % ) and h and -washing  before delivery ( 74 % ) , were common . Other beneficial practice s , such as thermal care , were low . Trained TBAs were more likely to wash h and s with soap before delivery , use a clean delivery-kit , and advise feeding colostrum . Although mustard oil massage was a universal practice , 52 % of the TBAs indicated their willingness to consider alternative oils . Low-cost , evidence -based interventions for improving neonatal outcomes might be implemented by TBAs in this setting where most births take place in the home and neonatal mortality risk is high . Continuing efforts to define the role of TBAs may benefit from an emphasis on their potential as active promoters of essential newborn care Newborn cord care practice s may directly contribute to infections , which account for a large proportion of the four million annual global neonatal deaths . This formative research study assessed current umbilical and skin care knowledge and practice s for neonates in Sylhet District , Bangladesh , in preparation for a cluster-r and omized trial of the impact of topical chlorhexidine cord cleansing on  neonatal mortality and omphalitis .  Unstructured interviews ( n=60 ) , structured observations ( n=20 ) , rating and ranking exercises ( n=40 ) and household surveys ( n=400 ) were conducted to elicit specific behaviors regarding newborn cord and skin care practice s. These included h and -washing , skin and cord care at the time of birth , persons engaged in cord care , cord cutting practice s , topical applications to the cord at the time of birth , wrapping/dressing of the cord stump and use of skin-to-skin care . Overall 90 % of deliveries occurred at home . The umbilical cord was almost always ( 98 % ) cut after delivery of the placenta , and cut by mothers in more than half the cases ( 57 % ) . Substances were commonly ( 52 % ) applied to the stump after cord cutting ; turmeric was the most common application ( 83 % ) . Umbilical stump care revolved around bathing , skin massage with mustard oil and heat massage on the umbilical stump . Overall 40 % of newborns were bathed on the day of birth . Mothers were the principal provider for skin and cord care during the neonatal period and 9 % of them reported umbilical infections in their infants . Unhygienic cord care practice s are prevalent in the study area . Efforts to promote h and -washing , cord cutting with clean instruments and avoiding unclean home applications to the cord may reduce exposure and improve neonatal outcomes . Such efforts should broadly target a range of caregivers , including mothers and other female household members BACKGROUND Omphalitis contributes to neonatal morbidity and mortality in developing countries . Umbilical cord cleansing with antiseptics might reduce infection and mortality risk , but has not been rigorously investigated . METHODS In our community-based , cluster-r and omised trial , 413 communities in Sarlahi , Nepal , were r and omly assigned to one of three cord-care regimens . 4934 infants were assigned to 4.0 % chlorhexidine , 5107 to cleansing with soap and water , and 5082 to dry cord care . In intervention clusters , the newborn cord was cleansed in the home on days 1 - 4 , 6 , 8 , and 10 . In all clusters , the cord was examined for signs of infection ( pus , redness , or swelling ) on these visits and in follow-up visits on days 12 , 14 , 21 , and 28 . Incidence of omphalitis was defined under three sign-based algorithms , with increasing severity . Infant vital status was recorded for 28 completed days . The primary outcomes were incidence of neonatal omphalitis and neonatal mortality . Analysis was by intention-to-treat . This trial is registered with , number NCT00109616 . FINDINGS Frequency of omphalitis by all three definitions was reduced significantly in the chlorhexidine group . Severe omphalitis in chlorhexidine clusters was reduced by 75 % ( incidence rate ratio 0.25 , 95 % CI 0.12 - 0.53 ; 13 infections/4839 neonatal periods ) compared with dry cord-care clusters ( 52/4930 ) . Neonatal mortality was 24 % lower in the chlorhexidine group ( relative risk 0.76 [ 95 % CI 0.55 - 1.04 ] ) than in the dry cord care group . In infants enrolled within the first 24 h , mortality was significantly reduced by 34 % in the chlorhexidine group ( 0.66 [ 0.46 - 0.95 ] ) . Soap and water did not reduce infection or mortality risk . INTERPRETATION Recommendations for dry cord care should be reconsidered on the basis of these findings that early antisepsis with chlorhexidine of the umbilical cord reduces local cord infections and overall neonatal mortality BACKGROUND In rural India , most births take place in the home , where high-risk care practice s are common . We developed an intervention of behaviour change management , with a focus on prevention of hypothermia , aim ed at modifying practice s 
    Output:
    
Findings from this review suggest that documentation of cord-care practice s is not consistent throughout low- and middle-income countries , yet existing literature depicts a firm tradition of umbilical cord care in every culture .