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.”
