A newborn enters the world with one wound already present: the cut umbilical cord. In a hospital, that cord is usually cut with sterile equipment and left clean and dry. In many communities, especially where childbirth happens at home, the cord may be cut with whatever tool is nearby and then covered with a substance meant to help it dry or protect the baby.
That substance might be ash, soil, butter, oil, herbs, saliva, cow dung, or a powder made from burned roots. These practices did not begin because people were careless. They began because families were trying to care for newborns with the knowledge and materials they had. But some of those materials can carry bacteria that are dangerous for a baby in the first days of life.
One of those bacteria is Clostridium tetani, the cause of . When it reaches a newborn through the umbilical cord, the result can be neonatal tetanus, which means tetanus in the first 28 days of life. It is a terrible disease. It is also preventable. That is the hard part: babies still die from a disease we know how to stop.
This is not a story about blaming culture. It is a story about what happens when history, poverty, distance from care, vaccine access, and birth traditions meet a bacterium that lives in soil and animal waste. Public health has to deal with all of that at once.
What Tetanus Does
Clostridium tetani is found around the world in soil, dust, and animal feces. It can form spores, which are a tough, dormant form of the bacterium. Those spores can survive for years outside the body.
Tetanus does not spread from person to person. It starts when spores enter a wound and find the right conditions to grow. The cut umbilical cord can be that wound.
The bacterium makes a toxin called tetanospasmin. A toxin is a poison made by a living organism. This toxin travels along nerves and blocks the signals that normally tell muscles to relax.
In older children and adults, tetanus is often called lockjaw because the jaw muscles tighten. In newborns, the first sign may be that the baby stops nursing. A baby who could eat and cry normally in the first two days of life may, a few days later, become stiff, cry constantly, and have painful muscle spasms.
The spasms can be triggered by sound, light, or touch. A baby may arch backward and become rigid from head to toe. These spasms can interfere with breathing. Without hospital care, especially care that can support breathing, neonatal tetanus is often fatal.
There is no quick antidote once the toxin has attached to nerve tissue. Treatment can include human tetanus immune globulin, which is medicine made from antibodies that neutralize the toxin still circulating in the body. Doctors also use wound care, antibiotics, medicines to control spasms, and sometimes mechanical ventilation to help the baby breathe. That kind of care is not available in many of the places where neonatal tetanus still occurs.
Why the Umbilical Cord Needs Care
The umbilical cord stump is a small wound. It is warm, moist, and made of tissue that no longer has a blood supply. That makes it easier for bacteria to grow there.
Clostridium tetani grows best where there is little or no oxygen. That is called anaerobic growth. If a cord stump is covered with soil, dung, or another thick substance, it can create a low-oxygen place where tetanus spores can wake up, grow, and produce toxin.
This is why cord care is not a minor detail. The bacterium does not need to spread throughout the baby’s body to cause disease. It only needs a place to grow and make its toxin. The cord stump can provide that place.
A clean blade matters. Clean hands matter. A clean surface matters. What happens after the cord is cut also matters. Leaving the cord clean and dry is not neglect. In many settings, it is the safest form of care. In higher-risk home birth settings, a safe antiseptic such as chlorhexidine can give families a clear alternative to household substances.
Why Families Apply Substances to the Cord
It is easy to say, from a clinic or a university office, that no one should apply anything unsafe to a newborn’s cord. It is harder to change what happens in a birth room where the person with the most authority may be a grandmother, an aunt, or a traditional birth attendant who has helped deliver babies for decades.
In many communities, the cord is not seen as a small medical wound only. It may carry meaning about the baby’s entrance into the family, the child’s safety, or the proper way to protect a newborn. Some caregivers worry when the stump looks wet or is slow to fall off. A powder, oil, or paste may feel like active care. Leaving the stump alone may feel wrong.
That history deserves respect. But respect does not mean pretending every practice is safe. Applying soil, cow dung, ash, or other nonsterile substances to a fresh cord stump can introduce bacteria. If the mother has not been protected by tetanus vaccination, the baby may have little or no antibody protection.
Two claims can be true at the same time. First, families are often acting out of love and responsibility. Second, some cord practices raise the risk of severe infection and death. Public health work fails when it ignores either part.
What the Evidence Shows
Studies from African countries have documented a wide range of cord care practices. A 2023 systematic review looked at 17 studies of caregivers in Africa. It found that unsafe cord care remained common in some places, and that infants whose caregivers used improper cord hygiene had about 13 times the odds of neonatal sepsis compared with infants whose caregivers used proper hygiene.
Neonatal sepsis means a severe infection in a newborn. It is not the same disease as tetanus, but the same unsafe cord practices can make both more likely. In that review, 75.1% of the umbilical cords assessed in the included studies showed infection. That number should not be read as the rate for all of Africa. It comes from the studies included in the review. But it is still a clear warning that cord infection remains a real problem where clean care is not routine.
Older and newer studies also tell us what works. Tetanus vaccination during pregnancy, or before pregnancy, protects the baby because antibodies cross the placenta. Antibodies are proteins the immune system uses to fight germs and toxins. When a pregnant person has enough tetanus antibodies, the baby is born with some protection already in place.
Clean delivery practices reduce risk at the moment of birth. That means clean hands, a clean surface, a sterile or new blade, clean cord ties, and no unsafe material on the stump.
Chlorhexidine, an antiseptic medicine, can also help in the right setting. WHO recommends 7.1% chlorhexidine digluconate for cord care during the first week of life for babies born at home in settings with high newborn mortality. In lower-risk settings, including many hospital births, clean dry cord care is usually enough. The point is not to put gel on every cord everywhere. The point is to give families in high-risk settings a safe option that can replace soil, dung, ash, or other unsafe substances.
A Cochrane review of trials found that chlorhexidine cord cleansing reduced newborn deaths by about 19% compared with dry cord care in community settings with high newborn mortality. It also reduced omphalitis, which is an infection of the cord stump, by about 52%. Those are large reductions for a low-cost intervention.
The Scale of the Problem
The world has made major progress against neonatal tetanus. WHO estimates that about 787,000 newborns died from neonatal tetanus in 1988. By 2018, that estimate had fallen to about 25,000. A CDC review estimated 7,719 neonatal tetanus deaths worldwide in 2021.
Those numbers show what vaccination, clean delivery, and better newborn care can do. They also show why the work is not finished. A disease can fall by more than 90% and still kill babies in the communities least reached by health systems.
The global goal is called maternal and neonatal tetanus elimination. Elimination does not mean zero cases. WHO defines it as fewer than 1 neonatal tetanus case per 1,000 live births in every district of a country. That threshold is important because national averages can hide smaller areas where babies remain at risk.
As of December 2025, WHO and UNICEF reported that 51 of 59 priority countries had been validated as having eliminated maternal and neonatal tetanus as a public health problem. Eight countries had not yet reached that goal: Afghanistan, Angola, the Central African Republic, Nigeria, Pakistan, Papua New Guinea, Somalia, and Yemen.
In the WHO African Region, the countries still on that list are Angola, the Central African Republic, and Nigeria. Their challenges are not simple. Conflict, insecurity, weak roads, limited clinic access, missed vaccination opportunities, and distrust shaped by long histories all make prevention harder.
What Prevention Looks Like on the Ground
The prevention plan is not mysterious. WHO’s strategy includes tetanus vaccination for pregnant people, vaccination campaigns in high-risk areas, clean delivery and clean cord care, and reliable surveillance so cases are found and investigated.
Maternal vaccination is the first layer of protection. For women with no record of tetanus vaccination, WHO recommends five properly spaced doses over time. In a first pregnancy, two doses are given at least one month apart. Later doses extend protection for future pregnancies.
Clean birth kits are another practical tool. These kits can include a clean plastic sheet, a new razor blade, cord ties, and simple instructions. They do not solve every problem, but they can change the tools available at the exact moment they are needed.
Chlorhexidine works best when it is already in the home before birth and when someone has explained how to use it. Telling people, “Do not put anything on the cord,” may not be enough if that advice conflicts with what families have always been taught. Saying, “Use this gel once a day for the first week, and do not add anything else,” is clearer and more practical.
Traditional birth attendants also have to be part of the work. Training them does not mean giving up on skilled facility care. It means dealing with reality. If a baby is going to be born at home, the person attending that birth should know why a clean blade, clean hands, vaccination, and safe cord care matter.
This is also where trust is very important. Communities that have been ignored, talked down to, or served only during campaigns may not accept advice just because a poster says so. People are more likely to change a birth practice when the message comes through someone they know, in a language they use, with supplies they can actually get.
What Remains Difficult to Do
The hardest cases are often the least visible. Many babies with neonatal tetanus are born at home and die at home. Their births may not be registered. Their deaths may not be counted. A district can appear to have no cases because no one is hearing about the babies who die in the first week of life.
Surveillance is not just paperwork done by office staff upon receiving a report. Surveillance of these cases is how public health learns where prevention is failing. If a newborn dies after losing the ability to suck, becoming stiff, and having spasms, that death should trigger questions. Was the mother vaccinated? Who attended the birth? What was used to cut the cord? What was placed on the stump? Could other babies in that area be at risk?
Supply chains are another barrier. A country can recommend chlorhexidine, but that does not help if the gel is not available in the village where the birth takes place. A clinic can recommend tetanus vaccination, but that does not help if a pregnant person cannot safely reach the clinic, cannot miss work, or is turned away because of fees, distance, or poor treatment.
There is also the problem of mixed practices. A family may receive chlorhexidine and still apply herbs or dung because an elder insists on it. Or the gel may be used once and then replaced by a familiar substance. That is not a failure of intelligence. It is a sign that the intervention did not fully fit the social reality of the birth.
The Public Health Lesson
Neonatal tetanus is a disease of exposure, but it is also a disease of inequity. The spores are in soil around the world. What differs is whether a newborn’s cord is protected from those spores, and whether the baby has antibody protection from a vaccinated mother.
Where health systems work well, neonatal tetanus nearly disappears. Where vaccination is hard to get, births happen without clean supplies, and newborn deaths go uncounted, the disease can remain.
The answer is not to shame families. The answer is to close the gap between what families are trying to do and what newborns need to survive. That means vaccination that reaches people before birth. It means clean delivery supplies in homes, not only in clinics. It means safe cord care that families can understand, trust, and use. It means listening to the people who are actually in the room when a baby is born.
A new blade, clean hands, maternal vaccination, chlorhexidine where it is needed, and a trusted birth attendant who understands the reason for each step can change the first week of life. For neonatal tetanus, that first week is often where prevention succeeds or fails.
References
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Mullany LC, Darmstadt GL, Khatry SK, et al. Topical applications of chlorhexidine to the umbilical cord for prevention of omphalitis and neonatal mortality in southern Nepal: a community-based, cluster-randomised trial. Lancet. 2006;367(9514):910-918.
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National Institute for Communicable Diseases (NICD). Tetanus Frequently Asked Questions. Johannesburg, South Africa: NICD; 2017.
World Health Organization Regional Office for Africa. Maternal and neonatal tetanus. WHO AFRO website. Updated June 2026.
World Health Organization. Maternal and neonatal tetanus elimination: the strategies. WHO website.
UNICEF USA. Vaccines protect mothers and babies in Mali from maternal and neonatal tetanus. UNICEF USA website. Published May 13, 2024.