Essential Intrapartum Newborn Care Bulletin is a publication under the Department of Health EINC Scale up project with assistance from the World Health Organization and the Joint Program in Maternal Neonatal Health funded by AusAid. The findings, interpretations and conclusions expressed in this publication is entirely those of the authors and should not be attributed in any way whatsoever to the Department of Health, World Health Organization or the AusAid.

Monday, August 8, 2011

EINC Don'ts and Do's

Unnecessary Intervention:
Footprinting of newborns is currently still a widespread practice in the Philippines as means of identification of newborns. In the first few minutes following delivery, the newborn’s feet are pressed into a common inkpad and later pressed onto an identification sheet. Not only is this practice is usually done by untrained personnel with variable results, but more importantly also increases the risk of cross contamination among the babies. In 1988, the American Academy of Pedicatrics (AAP) and the American College of Obstetricians and Gynecologists (ACOG) stated that “individual hospitals may want to continue the practice of footprinting or fingerprinting, but universal use of this practice is no longer recommended.” In fact studies have demonstrated that the majority of infant footprints taken by hospital personnel prove inadequate for identification purposes, contending that DNA genotyping and human leukocyte antigen tests are better methods of identification. Moreover, the EINC practice of non-separation of newborn from the mother minimizes the risk of switching newborns. Mostly importantly it has been proven that healthy newborns placed with their mother soon after birth transition more easily to extrauterine life. They stay warm, cry less, are more likely to breastfeed and breastfeed sooner compared to babies separated from their mothers. Unnecessary separation of newborns from their mothers and the resultant postponement of latching on and rooming in and restrictions on breastfeeding seriously compromise colonization of the newborn with maternal skin flora, immunoprotection, milk production and eventual exclusive breastfeeding. Footprinting, should not interfere with the core steps that include skin-to-skin contact and non-separation of mother and baby from early initiation of breastfeeding.
Recommended Practices:
Skin-to-skin contact (SSC) is generally perceived to be an intervention for the provision of warmth and bonding. But its contributions to immunoprotection of the newborn and to the protection against hypoglycemia are not widely known and less appreciated. Furthermore, evidence from several studies show that skin-to-skin contact between mother and birth reduces crying, improves mother-baby interaction, keeps the baby warmer, aids in stabilizing the baby and helps women breastfeed successfully.
Effects on Breastfeeding
A meta-analysis by Moore et all which included 30 randomized and quasi-randomized trials compared early SSC with usual hospital care involving 1925 mother-infant dyads. They reported statistically significant positive effects of early SSC on breastfeeding at 1-4 months post-birth (10 trials; 552 dyads; OR 1.82, 95% CI 1.08, 3.07), and breastfeeding duration (7 trials; 324 dyads; WMD 42.55, 95% CI -1.69, 86.79). Trends were found for improved summary scores for maternal attachment behavior (6 trials, 396 participants) (SMD 0.52%, 95% CI 0.072) and maternal affectionate love/touch during observed breastfeeding (4 trials; 314 dyads) (standardized mean difference (SMD) 0.52, 95% CI 0.07, 0.98) and with early SSC. SSC infants cried for a shorter length of time (one trial; 44 participants) (WMD -8.01, 95% CI -8.98, -7.04). Late preterm infants had better cardio respiratory stability with early SSC (one
trial; 35 participants) (WMD 2.88, 95% CI 0.53, 5.23). No adverse effects were found.
Effects on the Infant’s Cardiorespiratory Stability
A study of Takahashi et al. compared the effects of different initiation and duration times of skin-to-skin contact on the stress port-birth in full-term infants. The first group began SSC 5 minutes or less after birth (birth SSC), while the second group began SSC after 5 minutes (ver early SSC). The birth of SSC group reached HR stability of 120-160 bpm significantly faster than very early SSC group by Kaplan-Meier analysis (p=0.001 by log-rank test). As for Spo(2) stability of 92% and 96%, no significantly between-group difference was found. Salivary cortisol levels were significantly lower between 60 and 120 minutes after birth in SSC group, continuing for more than 60 minutes compared with SSC group for 60 minutes or less after adjustment for salivary cortisol level at 1 minute besides infant stress factors (P=0.046). All these suggest that earlier SSC beginning within 5 minutes post birth and longer SSC continuing for more than 60 minutes within 120 minutes post birth are beneficial for stability of cardiopulmomary dynamics and the reduction of infant stress during the early period post birth.
Effect on Infant’s Body Temperature
In an early study, Christensson et al randomized 50 healthy, full-term, newborn infants to be kept either skin-to-skin with the mother (n=25 mother-baby pairs) or next to the mother in a cot “separated” (n=25 mother-baby pairs). The babies were studied during the first 90 minutes after birth. Axillary and skin temperatures were significantly higher in the skin-to-skin group. Babies kept in cots cried significantly more than those kept skin-to-skin with the mother.
Effect on Blood Sugar Levels
In the previously cited randomized controlled trial by Christensson et al., at 90 minutes after birth blood glucose levels were significantly higher and the return towards zero of the negative base-excess was more rapid in the skin-to-skin as compared to the “separated” group. The weighted difference WMC (fixed) was 11.07 95% CI [3.97. 18.17].
Effect on Immunoprotection
Close skin-to-skin contact between the maternal-infant dyad may also stimulate the mucosa-associated lymphoid tissue system.

Tondo Medical Center : Commitments that Effect Change by Donna Miranda

These days the staff of Tondo Medical Center (TMC) can only recall with nostalgia what was once the harried and busy atmosphere of its Neonatal Intensive Care Unit, but not without relief.In fact if there were anything noticeable, it was the great deal of pride, satisfaction and enthusiasm beaming from hospital director Dr. Victor de la Cruz who together with his hospital staff has managed to successfully initiate change within a short period of time. Nowadays the nurses at the NICU jokingly lament how awfully quiet it has become since NICU admissions have begun to dramatically decrease to 10.9 % of total deliveries from January to March 2011. In fact at the time of our visit, there were only two babies. The two nurses stationed at the NICU candidly inform us, “we don't seem to have any use for that here anymore” pointing to the warmer where a queue would usually form to warm delivered babies. And indeed they don’t – since they’ve started implementing the EINC program in the hospital where the only warmth that babies receive mostly come from their mothers through immediate skin-to-skin contact. The staff also seemed much more satisfied now that some of the unnecessary workload such as cord care and routine bathing of the babies have been done away with. Instead more attention is being reallocated to breastfeeding support and monitoring. Not only was it reassuring to see that non-separation of mothers and babies conscientiously practiced but that it was also a relief to know that even those weighing between 1.5 to 1.8 kg who needed closer monitoring and care were kept with their mothers in the newly created EINC room right beside the NICU. Thanks to complete staffing realignment, mother-baby dyads are now closely monitored at least 9 times a day, ensuring that the sufficient support and care is given to mothers and during recovery. The mothers seemed to be pleased, as evident in the following quotations:

Nakakapanibago po, kasi yung mga narakaraan kong panganganak di naman ganito ang ginawa…Pero para sa akin, maganda po ito sapagkat nakakasiguro ako na di mapalitan ang anak ko, kasi pag sa hospital ka nanganganak masarap po ang pakiramdam, kasi nakabonding ko na kaagad ang anak ko… -- Marie Claire De Leon – 33 F, G7P3 NSD

Happy–happy ako, damang dama ko na anak ko talaga siya. Hindi siya napapalitan. -- Mrs. De Leon

Pakiramdam ko, relax ako. Masarap ang pakiramdam kasi namalayan ko nasa dibdib ko ang baby ko. -- Mary Ana Labayani – 25 F, G1P1 CS
After only four months since the EINC Orientation Workshop conducted last January 2011, TMC has already made remarkable progress in reducing sepsis, preterm and maternal deaths reporting reporting zero cases in the last week of March. As early as eleven weeks after training and weekly supportive supervision meetings its performance of the 4 core steps of EINC has been >95% in their normal deliveries and >90% in their caesarean deliveries. Moreover, the rates of allowing mother to eat and walk without routine IVF placement (83%) and delivering in semi-upright position (97%) have been equally impressive. And while these numbers have yet to reflect the true statistical impact of EINC on outcome indicators, the consistent drop in TMC’s NICU admissions and increase in directly room-in babies hint at future improvement in the statistics if the EINC program is continually implemented as standard of care in hospitals. The TMC in Manila is a tertiary public medical center established in 1971 operating under the supervision of the Philippine Department of Health (DOH). Currently, it has eight hospital departments, and a 200-authorized bed capacity, 60 of which is allotted to the OB-Gyne Department. Spontaneous vaginal deliveries is the leading cause of admission in TMC. In 2009, obstetric cases alone comprised 47% of the total admissions. Located at North Bay Boulevard, Balut, Tondo, Manila, TMC caters to the health needs of the residents of Tondo and CAMANAVA (Caloocan, Malabon, Navotas, Valenzuela) area.The early success of TMC is due to the strong leadership and openness of its medical director Dr. Victor de la Cruz. His “handson” management style – sitting in weekly implementation meetings, watching out for potentially conflicting clinical practices that may arise in carrying out the EINC -- and his fervent support for the program has been instrumental in the rapid but fine-tuned implementation of the program. As well as making sure that the necessary changes are adapted according to the hospital’s available resources, needs and capacities. Already some significant changes in the hospital’s policy, physical environment and practice have been put in place such as the complete realignment of staffing that allows frequent monitoring of mother-baby dyads; construction of wooden wedges to allow mothers a semi-upright position during delivery; use of a unique EINC wrap for babies in skin-to-skin contact; revision of admission forms and doctors’ orders reflecting EINC practices; and promoting EINC awareness among patients by continuously showing the EINC video material at the outpatients waiting. Additionally, an EINC-friendly floor plan is already underway and included in the hospital’s next renovation budget. Surely change is never easy and Dr. De la Cruz is quick to remark that the process was not one without some resistances. But not enough reason to give up. In fact he proudly shares that “my strategy was to keep close to those who were most resistant (to the changes), constantly convincing them to give it a try. At first they were hesitant but unwavering persuasion eventually won them over.” This tireless dedication and enthusiasm is something he says he has learned from the EINC Team whose supervised monitoring, committed support and guidance were crucial to TMC’s success. Dedication he said is not only infectious but inspiring, “how can you think otherwise, when the evidence is indisputable and safety of patients always prioritized over everything else.” Dr. De la Cruz receives the same kind of esteem from his staff who considers his openness to change and all-out support for the program as pivotal factors contributing to TMC’s successful and timely implementation of EINC -- attitudes that the staff now share with him. “The changes were not done abruptly, every week we do our commitments and then commit to do doing better for the following week. The staff is challenged to give our commitments weekly,” shares Dr. Sharon Macasadia, OB, on how they’ve managed to carry out EINC practice at a steady pace in the hospital. She further says that because of this they’ve learned to value these “incremental changes” and see how it affects the big picture. For instance she proudly cites how the use of intravenous fluids among delivering mothers has markedly dropped from 83.65% in February to 39.92 % in the last week of June. Adopting the EINC protocols has also made them appreciate the value of teamwork, pedia consultant Dr. Sheryl Joy Gracilla shares that “things are less departmentalized as we have learned to become more responsive in providing for the care of our patients.” Consequently, the non-departmentalization of care has resulted in better relationship between obstetricians and pediatricians, and of course, better satisfaction of its patients. Meanwhile the team is anticipating an even better working rhythm between the pediatrics and OB department as soon as the design of patients’ birth plan forms has been finalized. And as if things were not looking bright enough, TMC has not only managed to reduce infant sepsis and mortality rates but also incur savings cost since they’ve adopted EINC at the beginning of the year. The NICU charges, for instance have dropped from P145.00 to P43.50 and delivery room charges from P345.50 to P83.50. The savings are being reallocated to provide patients with EINC-friendly facilities. Moreover, a “free blood culture” service has been initiated to created provide free blood CS to indigent patients who cannot afford outside lab (because TMC’s lab has no blood cultures). Upon approval of Dr. Dela Cruz part of rebates from this outside lab has been converted to “free blood cultures” to selected newborns of indigent mothers.” The benefits reaped by simple health worker behavior change wereso impressive that TMC thought that EINC should not be confined within its walls. As a referral facility, TMC saw the need to share their experiences with other lower level facilities within their catchment area. In March 2011 TMC initiated an EINC training for 72 participants composed of nurses, pediatricians, obstetricians, administrators, clinical nurse instructors from Tondo’s catchment areas, including nearby Caloocan and Navotas, LGU-operated health units (Ospital ng Tondo, Pagamutan ng Bayan) and guests from tertiary medical centers (Gat Andres, VRPMC, Trinity, Delgado Hospital). The initiative to adopt EINC as the standard of care in all of these facilities is a manifestation of the system-wide effort to decrease the maternal and newborn mortality rates in the area. Dr. de la Cruz emphasizes, “We want to be part of the achievement of MDG 4 & 5, as I believe that focusing on MG 4 & 5 is a key step in solving the rest of the other MDGs.”

EINC friendly Birth Center to Open at EAMC

This July, East Avenue Medical Center (EAMC) is slated to complete its Birthing Center. To be headed by Dr. Elenita Veloso, the Birthing Center now has a spacious examination room, a spacious EINC area to accommodate mother-baby dyads with 30 reclining beds, and an OR for emergency CS cases. After touring the premises, the EINC working group has expressed its satisfaction with the Birthing Center’s steady development, forseeing further improvement in the OB Department’s already impressive statistics. Since EINC was implemented in April, performance of unnecessary practices have steadily gone down, and there has been very good compliance with performance of complete EINC, even in CS deliveries. From July 11-17, 2011, out of 123 normal deliveries, 58.5% had episiotomies and these were mostly young primigravid teenage mothers with tight perineums. 52.8% were not given IV fluids, and the remaining patients with IVs were OB complicated cases which comprise the majority of their admissions (65.7% of all admissions). The wall to wall stretchers in the DR don’t allow for patients’ mobility or having position of choice during labor, but 69.9% are able to deliver in the semi-upright position. More commendable is the 100% use of antenatal steroids, 100% EINC in CS deliveries, and performance of core steps 1-3 even in symptomatic patients. This ensures that all patients benefit from EINC even if they are eventually admitted to the NICU. The Birthing Center, however, is not without room for improvement in its facilities. The EINC working group has suggested the addition of a sink in the IE room, the expansion of the labor room by way of converting the large area around the nurses’ station, the addition of handwashing stations in the delivery room, and the installation of exhaust fans. There remain many opportunities for the physical improvement of the space.

More Comfort from Mommy-friendly Beds in JRMMC

June 3, 2011 – All delivery beds in Jose Reyes have been made “mommy-friendly” by fitting them with special wedges so mothers now deliver in non-supine positions. “Mothers are more comfortable, there have been no complaints, reported Dr. Francesca Tatad-To, Team EINC Co-Convener. This was reported during a weekly review of EINC progress in May 2011. This innovation is a welcome addition to the low sepsis rates among term babies and low mortality rates, both at less than 1%. During this period, NICU admission rate was 10% of all deliveries. The innovation of letting mothers have a “position of choice” comes as a result of the repeat delivery observations and time motion studies. Other changes have been instituted. The ER pharmacy is ensuring that dexamethasone is in stock. The OBGYN doctors are now revising their NPO orders to allow mothers to eat/drink. The partographs are going to be placed in charts in a more timely manner. Foot printing, a cause of potential infection for newborns, is going to stop with changes being done to hospital forms after reviewing the new guidelines in AO 2009:2

5.

Sunday, June 26, 2011

QUIRINO MEMORIAL MEDICAL CENTER EXPERIENCE: Accepting the challenge of change by Donna Miranda

The Quirino Memorial Medical Center (QMMC), formerly known as the “labor “ hospital in Quezon City, was among 51 government-run hospitals included in a comprehensive study on prevailing newborn care practices in the Philippines starting November, 2008.

In hindsight, Dr. Belle Vitangcol, head of QMMC’s pediatrics department and lead ENC trainor, remembers this as the starting point of a whirlwind that in barely one year’s time would sweep away many traditional practices and attitudes in the delivery room, and usher in a radically different regimen on essential newborn care.

Even before researchers backed by he Department of Health and the World Health Organization began setting up monitoring stations at the hospital, Vitangcol and her medical colleagues knew something had to change. QMMC, which grew steadily from a 75-bed facility when it first opened in 1953 to the 350-bed center today, was sagging with maternity patients two-to-a-bed. A tertiary referral center for high risk pregnancies, average deliveries had jumped from an average of 500-600 a month in 2008 to about 800 in 2009, among the largest number of deliveries in any single hospital that year (9,605).
The DOH-WHO study noted that QMMC, like many other hospitals, reflected the country’s high incidence of neonatal deaths.

Overall, 82,000 Filipino children die annually (2008) before the age of five, 45 % of them neonates. Almost half of newborn deaths occur in the first 28 days, a quarter of them in the first two days of life. The three major causes are complications of prematurity (41%), sepsis and pneumonia (16%), asphyxia (15%).

The study confirmed that current practices in Philippine hospitals fell below recommended WHO standards and robbed newborns of the natural protection offered by four recommended basic interventions: immediate and thorough drying, skin to skin contact, properly timed cord clamping and early initiation of breastfeeding.

Cords were immediately clamped at a median of 12 seconds, far too soon. Less than 1 in 10 babies was placed in direct skin-to-skin contact with the mother. Many newborns were exposed to cold by not being dried immediately and thoroughly, and being put on cold surfaces. All were washed early and 80% were suctioned unnecessarily, noted Dr. Howard Sobel, head of the WHO team for maternal and child care, in a presentation of the findings in 2009.

Neonatal death rates in the Philippines had changed minimally in the past 15 years. Health authorities noted that if the country was to meet its Millennium Development Goal of reducing child deaths by two-thirds, drastic changes needed to be made in neonatal care—and fast.
QMMC medical and staff executives involved in maternal and child care were invited to seminars to review the evidence for the WHO recommended interventions and other new practices incorporated in the DOH’s Basic Emergency Obstetric and Newborn care (BEmONC) program.

HOSPITAL POLICY

Dr. Vitangcol said she and many of her colleagues needed little convincing. “If anything, (the workshops) provided the confirmation and framework for some piecemeal improvements we had been slowly trying to put into place,” she said. The hospital staff was already following guidelines on delayed bathing, early breastfeeding protocols and rooming-in.

After the initial study on current practices, the WHO maternal and child health team had approached QMMC to allow them to conduct a pilot study and further test the effectiveness of the new time-bound Essential Newborn Care (ENC) interventions.

In the first quarter of 2009, the QMMC’s Hospital Ethics Review Committee approved the pilot proposal. It included a study on “The Effect of a Package of Newborn Care Interventions on the Incidence of Neonatal Sepsis” and a randomized controlled trial on “Timing and Positioning of Cord Clamping.”
Nationwide, the introduction of the WHO Essential Newborn Care Course was launched.

“Well, the rest is history,” said Dr. Vitangcol smiling. But it was not that easy, she was quick to add.

STAFF TRAINING AND MANPOWER CONCERNS

With a new hospital policy in favor of the ENC shift in place, training seminars were organized.
By September 2009, all pediatric, obstetric, midwifery and related nursing staff were trained in the essential newborn care protocol. Workshops were also held for deans and clinical instructors of nursing schools affiliated with the QMMC.

Time and motion studies conducted during the pilot implementation period, however, showed that old practices were not that easily shed.

The new interventions required longer waiting periods—more meticulous drying of the newborn; more supervision during skin-to-skin contact; delayed cord clamping and cutting, and a waiting time of 20 minutes to up to two hours for breastfeeding initiation.

Monitors noted that some staffers did not continuously check the position of mother and baby or wait long enough for some babies to begin breastfeeding. Some monitors even caught nurses handling babies without thoroughly washing their hands.

Many complained of lack of time given the many patients in the labor and delivery rooms. Everybody complained of overwork.

“If there is one lesson we can immediately share, it is that training is not enough,” said Dr. Vitangcol.
Some interventions were more easily implemented: delayed cord clamping, the no bathing rule and brief skin-to-skin contact.

Harder to implement were the protocols on longer skin-to-skin contact and breastfeeding support up to 90 minutes. Surprisingly, adherence to strict hand washing immediately before and after handling of patients was a tough one.

In assessment meetings in November, the ENC working team identified several key barriers to implementing the WHO protocols. These included physical arrangement of the delivery room and equipment, staff resistance to change their established practices, staff misperceptions of what was really happening (and its consequences) and the availability of some essential medications (e.g., antenatal steroids, oxytocin and antibiotics).

They collected more baseline information to show the hospital staff how the interventions were inadequately applied and the consequences of their current practices.

Spot hand and environmental cultures were also done.

The hospital staff then agreed on steps to address the problems.

The mothers, too, had to understand the new process and be convinced of the benefits to their newborn.

HOSPITAL INFRASTRUCTURE AND SUPPLIES

The ENC team leaders continuously reviewed the system. The longer time needed for skin-to-skin contact and breastfeeding initiation were for the good of the mother and baby and therefore was non- negotiable. But certain refinements were possible.

A breakthrough came with a simple strategy: rearranging the furniture in the delivery room. They took away the old steel tray where newborns used to be placed.

The nurses’ table was moved to the recovery room so there would be more supervision of mother and baby’s needs. It also allowed them to chart case experiences.

Delivery tables were cranked up to allow mothers to birth in sitting position if they so desired. When preferences were monitored, two-thirds of the tables were permanently placed in upright position.
One room was vacated to serve as walking space for mothers in labor. Unlike before, food and drinks were also allowed in the labor room.

“Actually, we discovered that we really didn’t need new and expensive equipment to implement the changes. “

They noted the positive effects of the physical changes on work habits.

Dr. Vitangcol recalled that at every meeting they would ask themselves what other changes could be made: ‘Are the routine things we used to do really necessary?’

For example, the giving of routine Intravenous fluid (IVF) was abandoned. The obstetricians agreed that it was not really necessary in normal, low-risk mothers. Routine antibiotics and the shaving of perineal areas were also stopped. Episiotomies were reduced.
Letting go of practices which new evidence had shown to be unnecessary in all cases helped reduce the staff’s workload. It has also led to less stress and more comfort for the mother and the newborn.

MULTIDISCIPLINARY APPROACH, INTERNAL AND EXTERNAL PRESSURE

By November 2009 the follow-up meetings were scheduled weekly with representatives from the delivery room staff, the nursing staff, NICU staff, pediatrics and obstetrics. Anesthesia staff and infection control committee members were invited as needed.

Results of follow up data were presented at the weekly meetings to decide if further information and interventions were needed. Barriers were addressed in a prioritized order.

For stricter hand washing, the staff made it a point to voice the question before every delivery: ‘Have we all washed out hands?’ Staffers were also provided with pocket alcohol gel for sanitizing hands when scurrying from one patient to another. Posters reminding the staff of this requirement were increased.

POLITICAL WILL, CONSTANT MONITORING

While addressing the problems one by one, “we also impressed upon the staff that the administration was determined to implement the new system,” that there was no turning back, said Dr. Vitangcol.
She added that it helped that the team had the backing of powerful institutions like the Department of Health and the WHO. “We are being watched,” I would warn the staff.

“I was like a policeman,” she laughed.

“I believe one big reason we were able to comply was because someone from the outside was looking into our set-up,” reflected Dr. Vitangcol. The DOH and WHO officials had assigned watchers for the pilot study and were themselves often in the hospital premises. National monitoring and reporting systems were being designed.

“We were all on our toes…careful,” she added.

But she stressed that the internal team had long decided that they were serious about change: There would be no whitewashing of data, no cover-ups of weaknesses.

Dr. Vitangcol also said her team could not have implemented the change without the full support of the hospital administration. The director and almost all related department heads had attended the ENC echo seminars. They gave the ENC working group all-out support.

SHOWING RESULTS: A TASTE OF SUCCESS

While keeping up the pressure, the team knew that only one thing could cement the changes: Showing the staff that the new system was really working.

The goal was clear: to reduce the hospital’s neonatal mortality and morbidity incidence.
Six months into the program, Dr. Vitangcol said a drop in the sepsis rate was palpable but too soon to call.

By December 2009, it was reported in the weekly meetings of the ENC working group that admissions to the neonatal intensive care unit (NICU) were down by a third. It was also reported that all mothers were already birthing off their backs (100%), episiotomy rates had been cut (90 %), and perineal shaving, routine antibiotics and IVFs had been eliminated. Monitors reported dramatic improvements in hand washing and the non separation of mother and baby until breastfeeding initiation.

The last WHO-led assessment in February and March 2010 noted the improved compliance with the new protocols: “95% of newborns were dried immediately and placed in skin-to-skin contact, about 90% had their cord clamped after 60 secs and three-fourths had breastfed appropriately. Similarly, unnecessary suctioning decreased to 2.3% and none were bathed early.

By this time too, the DOH had incorporated the WHO interventions into a mandatory protocol. At the launching of the protocol together with a public information campaign dubbed “UnangYakap,” the QMMC pilot experience was highlighted. The media attention it elicited gave the QMMC a rush.

INITIAL BENEFITS, CONTINUING DRIVE

By May 2010, barely a year since the change project began, hospital director Angeles T. de Leon was confident enough to report some preliminary findings during a Maternal Neonatal and Child Health and Nutrition forum in Cebu City.

Benefits to mother and child were almost immediate, she reported.

To their compliance with the more thorough drying technique as a first step, De Leon attributed better thermal care and stimulation of breathing, and therefore less need for ventilator support to newborns;
To early skin to skin contact, she linked greater warmth, the prevention of hypoglycemia and heightened mother and child bonding. It also made cord clamping easier to perform.

Non separation of the newborn from the mother for the first breastfeeding resulted in higher breastfeeding rates on discharge at seven and 28 days (89% and 69%, respectively). Mothers also reported a more satisfactory feeding experience. The practice has led, she said, De Leon reported, to lower NICU admissions and therefore a better NICU nurse to patient ratio. There were also less sepsis cases and shorter hospital stays.

Changes in maternal care--for example, allowing mothers a position of choice for birthing and letting them walk, eat or drink during labor-- resulted in shorter duration of labor, she also reported.
QMMC had stopped the practice of unnecessary suctioning to drain secretions and induce breathing. The baby in prone position on the mother’s abdomen or chest did the job, while lowering the risk of death and sepsis, De Leon said.

Benefits to hospital administration were the added bonus, she said.
The recommendations for cord clamping (use of plastic clamp and forceps, no milking and no antiseptics) resulted in savings on time and supplies of cotton, alcohol and iodine. They were also able to do away with separate cord dressing rooms and tables.

The ‘no automatic suctioning’ policy meant hospital savings on suction catheters, tubing, electricity, oxygen suction bulbs and others.

Footprinting of babies was done away with. This eliminated the need for ink pads which increased the risk of infection. The elimination of other formerly routine procedures like episiotomies, enemas, shaving, IVF and prophylactic antibiotics also resulted in savings in both time and supplies.
It resulted in shorter delivery room stays as well. Obstetric residents also reported less dehiscence of episiotomy wounds upon outpatient follow-up.

De Leon showed hospital administrators their calculation of the savings: more or less P465.50 on each normal delivery (just from eliminating blades, cotton, alcohol, iodine, tubing, IVF, catheters, sutures, enemas, rubber bulbs, and other supplies). For QMMC, which handled 6,670 normal births during the study period, this added up to savings of P3.1 million.

By August 2010, the WHO team released the official findings of the pilot studies: newborn deaths had been cut by almost half and there was a 70% reduction in neonatal sepsis despite the higher total percentage of pre-terms.

LESSONS AND CHALLENGES AHEAD

Dr. Vitangcol and the rest of the ENC working group know they cannot let down their guard. “There is a fast turn-over of staff in the delivery room and the young nurses are still schooled in the old methods. Kailangantutoktalaga (you really have to keep close watch). There is always the danger of backsliding.”
But it’s much easier now to keep going. “I think it’s because we get more ‘thank you’s’ from the mothers, “she added.

“I make my rounds in the morning and ask the mother’s about their birthing experience. They seem less stressed, more positive and comfortable.”

Summing up QMMC’s experiences, De Leon noted: “We were ready for the change and we were prepared to act decisively, to accept that change was necessary despite many imperfect conditions and difficulties.”

Up to now, mothers often still have to bunk two-to-a-bed in QMMC’s overcrowded and harried maternity wards, which service not just Quezon City residents but also those from surrounding towns of Marikina, Antipolo, San Mateo, Montalban, Caloocan, Novaliches and even nearby provinces of Laguna, Bulacan and Cavite.

“But we decreased the maternal mortality rate and we even reaped savings for QMMC, “she continued.
What it really took, she concluded, was “the political will and a listening heart to accept the challenge of change.”

Are Newborn Care Practices Done Properly within the First Hour of Life? A Survey on 51 of the Largest Hospitals in the Philippines

The Philippines is one of 42 countries accounting for 90 percent of all global deaths in children under 5 years of age with 82,000 Filipinos die before reaching their 5th birthday. There are also over 40,000 newborns who die annually. And if newborn mortality is not reduced by half, the goal of reducing childhood mortality by two thirds, which is part of the Millennium Development Goals, will not be met.

In a study of consecutive deliveries in 51 of the largest hospitals in 9 regions in the Philippines, an assessment tool developed by the World Health Organization (WHO) as a standard in Newborn Care which included the evidence-based intervention, was used to evaluate the performance, timing of procedures and attendant capabilities in immediate newborn care.

The Intrapartum/Newborn Practices assessment tools were developed through a collaboration between the Philippine General Hospital and World Health Organization(WHO) with Department of Health (DOH) inputs. In this cross – sectional study in 2009 using a brief questionnaire and annual reports such as hospital births, deaths and sepsis cases, approximately 10 babies were consecutively included from each of the randomly selected 51 hospitals.

These evidence-based interventions include immediate drying, skin-to-skin contact followed by clamping of the cord and non-separation, and breastfeeding initiation. Necessary interventions like immunizations, eye care, vitamin K administration was also timed. Unnecessary procedures such as “routine” suctioning, “routine” separation of newborns for “observation”, giving of glucose water or formula and footprinting (increasing risk of contamination from ink pads) was also identified.

A total of 481 mother-newborn dyads were directly observed. The percentages and median times to the following included cord clamping (12 sec), drying (93.8% at 1 min), skin-to-skin contact (9.6% at 4 min) and any early contact with mother (61.1% at 5 min), washing (84.2% at 8 min), breastfeeding initiation (61.3% at 10 min), separation from mother (93.2% at 12 min), weighing (100% at 13 min), examination (75.7% at 17 min), transfer to a nursery (52.4% at 20 min), eye prophylaxis (99.8% at 20 min), injections of vitamin K/vaccines (95.6% at 22 min) and rooming-in (83.4% at 138 min). Only 1 of 26 apneic or gasping newborns was dried prior to other actions.

It was found from the study that among the randomly selected 51 hospitals in the Philippines, performance and timing of evidence-based interventions in immediate newborn care were below WHO essential newborn care standards. In these hospitals, their practices prevented Philippine newborns from benefiting from their mothers’ natural protection in the first hour of life and almost none in the study newborns benefited from the natural transfusion from delayed cord clamping. It should be known that any unnecessary delay and restriction on immediate thorough dring, early and sustained skin-to-skin contact, early latching, rooming in and full breastfeeding, compromised the newborns’ chance for maintenance of warmth and survival beyond the newborn period. Further, these interventions can be integral to hospital infection control practices as they directly reduce risk of neonatal sepsis.

UnangYakap Embraces 8,962 Healthcare Professionals

Dr. Mianne Silvestre, EINC Team Convenor and WHO Consultant, reports that at least 8,962 healthcare professionals are now aware or knowledgeable in essential intrapartum and newborn care (EINC) practices. We believe this means that mothers and newborns will benefit from safer, quality care from these health facilities.

“From October to May 2011, we tripled our goals when requests for the EINC training course, spontaneously came from private hospitals (12%) and public hospitals in provinces outside NCR (6%).

The biggest chunk of awareness still comes from those who attended lectures of our EINC team or talks provided at special forum (53%). But this number appears understated.

Dr. Silvestre pointed out that it does not capture the number of readers or listeners who have heard the DOH Family Health Office Director Dr. Ed Janairo or Dr. Anthony Calibo on radio and television talk about the benefits of adopting the EINC practices.

Drop in Maternal and Newborn Deaths marks 8th week of EINC in General Santos City

Dr. Orlando Marius Oco Jr., Chairperson of the Local Health Board of General Santos City said they were encouraged by the feedback that there has been a dramatic drop in the NICU admissions, decreasing rates of preterm and sepsis deaths and an overall decrease in maternal and newborn deaths after 8 weeks of implementation of the EINC Scale Up Project.

Dr. Oca said this as he welcomed the participants, project staff, conveners and resource speakers of the orientation workshop on Essential Intrapartum and Newborn Care last May 25, 2011.Dr. Oca cited the recent world health report which seeks to make every mother and child count. The United Nation says that almost 11 million children under 5 years of age will die from causes that are largely preventable. Among them are 4 million babies who will not survive the first month of life. At the same time, more than half a million women will die during pregnancy or childbirth. The report says that reducing this toll in line with the Millennium Development Goals depends largely on every mother and every child having the right access to healthcare from pregnancy through childbirth, the neonatal period and childhood.

The Health Board Chair said the City of General Santos was grateful that General Santos City Hospital had been identified by the Department of Health as the collaborating institution in the SOCCSKARGEN Region to implement the Essential Intrapartum and Newborn Care protocol in the area.

More than 500 health professionals from General Santos City, Kidapawan, Sultan Kudarat, Tacurong, Polomoloketc braved the rains to attend the EINC orientation workshop held over 3 days at the Lagao Auditorium in General Santos City.

He ended his welcome by reminding the health professions that “we do not rest on our laurels or wallow in defeat, we will take honor in this opportunity to learn and serve and in this privilege to host this workshop”. And with the warm salutation “ You are in the home of the Generals!!!Good day to all and “ Magandang Gensan”!

 
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