International Journal for Quality in Health Care, 2018, 30(7), 537–544

doi: 10.1093/intqhc/mzy049
Advance Access Publication Date: 31 March 2018
Article

Article

Improving immediate newborn care practices in

Downloaded from https://academic.oup.com/intqhc/article/30/7/537/4957982 by Seeley G. Mudd Library user on 26 November 2024

Philippine hospitals: impact of a national quality
of care initiative 2008–2015
MARIA ASUNCION A. SILVESTRE1, PRIYA MANNAVA2, MARIE
ANN CORSINO1,3, DONNA S. CAPILI1, ANTHONY P. CALIBO4, CYNTHIA
FERNANDEZ TAN5, JOHN C.S. MURRAY2, JACQUELINE KITONG6,
and HOWARD L. SOBEL2
1
Kalusugan ng Mag-Ina, Inc. (KMI; Health of Mother and Child), Quezon City 1103, Philippines, 2Reproductive,
Maternal, Newborn, Child and Adolescent Health Unit, World Health Organization Western Pacific Regional
Office, Manila 1000, Philippines, 3Department of Pediatrics, Remedios Trinidad Romualdez Medical Foundation,
Tacloban City 6500, Philippines, 4Family Health Office, Disease Prevention and Control Bureau, Department of
Health, Manila 1003, Philippines, 5Dr Jose Fabella Memorial Hospital, Manila 1003, Philippines, and 6Reproductive,
Maternal, Newborn, Child and Adolescent Health, Office of the World Health Organization Representative in the
Philippines, Manila 1003, Philippines

Address reprint requests to: Howard L Sobel, World Healh Organization Regional Office for the Western Pacific, P.O.
Box 2932 (United Nations Avenue) Manila, Philippines. Tel: +6325288001; Fax: +6325211036; E-mail: [email protected]
Editorial Decision 1 March 2018; Accepted 22 March 2018

Abstract
Objective: To determine whether intrapartum and newborn care practices improved in 11 large
hospitals between 2008 and 2015.
Design: Secondary data analysis of observational assessments conducted in 11 hospitals in 2008
and 2015.
Setting: Eleven large government hospitals from five regions in the Philippines.
Participants: One hundred and seven randomly sampled postpartum mother–baby pairs in
2008 and 106 randomly sampled postpartum mothers prior to discharge from hospitals after
delivery.
Interventions: A national initiative to improve quality of newborn care starting in 2009 through
development of a standard package of intrapartum and newborn care services, practice-based
training, formation of multidisciplinary hospital working groups, and regular assessments and
meetings in hospitals to identify actions to improve practices, policies and environments. Quality
improvement was supported by policy development, health financing packages, health facility
standards, capacity building and health communication.
Main outcome measures: Sixteen intrapartum and newborn care practices.
Results: Between 2008 and 2015, initiation of drying within 5 s of birth, delayed cord clamping, dry
cord care, uninterrupted skin-to-skin contact, timing and duration of the initial breastfeed, and
bathing deferred until 6 h after birth all vastly improved (P<0.001). The proportion of newborns
receiving hygienic cord handling and the hepatitis B birth dose decreased by 11–12%. Except for
reduced induction of labor, inappropriate maternal care practices persisted.

© The Author(s) 2018. Published by Oxford University Press in association with the International Society for Quality in Health Care. All rights reserved.
For permissions, please e-mail: [email protected] 537
538 Silvestre et al.

Conclusions: Newborn care practices have vastly improved through an approach focused on improv-
ing hospital policies, environments and health worker practices. Maternal care practices remain out-
dated largely due to the ineffective didactic training approaches adopted for maternal care.

Key words: newborn care, clinical practice, quality improvement, quality of care, Philippines

Introduction maternity services purposively added to give a total of 51 hospitals (meth-

Downloaded from https://academic.oup.com/intqhc/article/30/7/537/4957982 by Seeley G. Mudd Library user on 26 November 2024

Globally, newborn mortality has fallen at a rate slower than that of ods described in detail elsewhere) [13]. The 2015 assessment included 17
older infants and children under five [1, 2]. Consequently, nearly half hospitals where EINC was implemented between 2010 and 2015. This
of all under-five child deaths in low or middle-income countries occur sample included all 11 hospitals where EINC was first implemented in
in newborns (0–27 days) [2]. Although a minimum package of cost- 2010 and 2011—‘early implementation hospitals’—and purposive selec-
effective interventions to reduce newborn mortality has been identified, tion of six large hospitals from four regions where scale-up was conducted
multiple systems problems limit access to quality care [3–5]. As a later in 2012–2015. The availability of clinical practice data from 2008,
response, global partners developed The Every Newborn Action Plan prior to the intervention, provided an opportunity to conduct a longitu-
(ENAP) in 2014 [6]. Although small-scale projects have demonstrated dinal observational study to compare trends in practice at the 11 hospitals
improved newborn care, none have been translated into country-level common to both assessments. Of these hospitals, six were early imple-
programs [7–10]. Data on improving quality of maternal and newborn mentation (2010–2011) and five were later implementation (2012–2015).
care at scale are scarce in countries with limited resources [11]. We
report here on what we believe to be the first large-scale national initia-
tive to improve the quality of immediate newborn care. National intervention
In the Philippines, an estimated 82 000 of 2.4 million children die Figure 1 outlines the process followed to improve quality of intrapar-
annually before their fifth birthday with half occurring among new- tum and newborn care in the Philippines. Between 2009 and 2011,
borns [12]. While post-neonatal deaths decreased between 1990 and DOH and WHO worked with professional organizations and other
2005, neonatal mortality did not [12], thus mirroring the epidemio- stakeholders to review and update newborn clinical practice guidelines
logical pattern found in other low- and middle-income countries [2]. using the Grading of Recommendations, Assessment, Development
Following a deadly outbreak of early neonatal sepsis in an urban and Evaluation (GRADE) approach to assess quality of evidence [19,
hospital in 2008, an assessment of intrapartum and immediate new- 20]. Through this process, a package of evidence-based interventions
born care in 51 large hospitals revealed inappropriate practices in called EINC was adopted for the Philippines. DOH then issued
the 481 deliveries observed [13]. For example, <10% of the new- updated policies [21, 22], the Philippine Health Insurance Corporation
borns received skin-to-skin (STS) contact despite its known benefits revised their newborn package based on the guidelines and updated
[13, 14]. Similarly, 95% of newborns were suctioned unnecessarily newborn care standards were integrated into midwifery, nursing and
[13] despite known risks [15, 16], and substances applied to the medical preservice curricula and licensure exams.
cord stump of 99% of newborns despite the global recommendation Clinical training and quality improvement methodologies targeting
for dry cord care [17, 18]. A number of other gaps were noted, health worker practice gaps were applied first in 11 government hospi-
including immediate cord clamping, early bathing and delayed tals (9 national and regional, 1 city and 1 university affiliated) [23, 24].
breastfeeding initiation [13]. A job aid based on the updated DOH newborn clinical practice
As a response, the Philippines Department of Health (DOH), guidelines [18, 20] including time-bound, step-by-step care of breathing
World Health Organization (WHO) and partners developed and and non-breathing babies and handwashing tasks was developed.
adopted a systems approach to improve newborn care practices. We Checklists were used by third party physician assessors to observe at
describe this national intervention and findings of hospital care least 10 deliveries and document labor, delivery and immediate new-
assessments conducted in 2008 and 2015 to investigate whether born care practices. Intensive practice-based training for hospital staff
practices had changed. Quantifying the effectiveness and sustainabil- was tailored to address identified practice gaps. Brief interactive didac-
ity of the Philippine approach is crucial for understanding the poten- tics were enhanced with coached return demonstrations in classroom
tial impact of future national programming. simulations using inexpensive dolls with improvised umbilical cords
and delivery room supplies. Particular attention was paid to discussing
evidence on harmful practices, e.g. delayed breastfeeding initiation and
routine separation of mother–newborn dyads. Over the next 6 months,
Methods multidisciplinary working groups including senior hospital managers,
Study design nursing, obstetric, neonatal, anesthesiology staff and external experts
This study used data collected from hospitals in 2008 and 2015, met weekly to address barriers and solutions to evidence-based prac-
before and after implementation of a national initiative to improve the tice, focusing on revising hospital environments to enable practice
quality of intrapartum and newborn care (essential intrapartum and change. Periodic clinical assessments using checklists were done.
newborn care—EINC), to compare changes in clinical practices over Actions undertaken by hospital working groups to address barriers to
time. The sampling frame for the 2008 assessment was 150 govern- evidence-based practices and gaps identified from clinical assessments
ment hospitals with the highest number of annual births in the included revising hospital policies, standard operating procedures,
Philippines. About 50 hospitals were randomly selected from 9 of 17 health worker roles and physical set-ups for deliveries. When neces-
regions and the largest hospital in the country exclusively providing sary, time–motion studies identified delays in provision of care.
Newborn care in the Philippines • Quality improvement 539

EINC package of interventions developed following review of

newborn clinical practice guidelines; Job-aid disseminated

National-level actions
(2009–11)
DoH issues updated newborn care policies
Philippine Health Insurance Corporation revises newborn care
package to include EINC

Downloaded from https://academic.oup.com/intqhc/article/30/7/537/4957982 by Seeley G. Mudd Library user on 26 November 2024

Newborn care standards reflecting EINC integrated in clinical
preservice curricula and licensure exams

Clinical training provided to hospital staff on correct childbirth and

Quality improvement approach introduced in 11 early implementation

newborn care practices

Support visits by third party physician assessors to observe hospital

staff practices based on standard checklists
hospitals (2010–11)

Assessors provide practice-based training and hold discussions with

staff to address clinical practice gaps identified from observations.

Multidisciplinary hospital working groups formed and hold weekly

meetings to discuss barriers and solutions to enabling practice change
and improving care.

Hospital working groups conduct periodic clinical assessments using

standard checklists. Findings used to identify actions to enable
practice change and improve care
National scale-up
(2012–15)

EINC hospital implementation manual developed based on the

quality improvement methodology used in the 11 early
implementation hospitals and used to support national scale-up.

Figure 1 Implementation of the essential intrapartum and newborn care (EINC) quality improvement approach in the Philippines.

An EINC implementation manual was developed based on the By the end of 2015, over 14 000 health workers in 252 hospitals
methodology (clinical training followed by a quality improvement pro- had been trained in the EINC quality improvement approach [26].
cess) used in the early implementation hospitals. [24, 25]. The manual Broader institutionalization of and demand for EINC was promoted
was used for national scale-up between 2012 and 2015 at both hospi- through national health professional associations which collabo-
tals and primary delivery facilities by DOH facilitators in collaboration rated to disseminate information, conduct training and increase
with Kalusugan ng Mag-Ina (KMI), a local non-governmental organ- awareness among health workers, as well as civil society organiza-
ization (NGO) with support from various partners. tions (CSOs) and NGOs which implemented social marketing
540 Silvestre et al.

activities to promote EINC and breastfeeding in communities 2–7 consecutive deliveries were observed on the day of the assess-
through social media and women’s support groups. In addition, ment visit and up to 10 postpartum women who had delivered in
national government departments such as the Department of Social the previous 24–72 h selected from admission registers using system-
Welfare and Development incorporated EINC into family develop- atic random sampling for a maternal interview and patient chart
ment counseling for the poorest families. Economic planning, review. Mothers with a stillbirth or early newborn death were
finance and budget ministries ensured budget allocation to support excluded for ethical reasons. The interview included information on
maternal and newborn health at national agencies and local govern- intrapartum and newborn care from the mothers’ narration of their
ment units, and inclusion in national medium and long-term devel- birth experiences. The patient chart review included data on clinical
opment plans. Local government units, in turn, allocated budget practices that could not be reliably reported by the mother. Women
lines to support facility infrastructure, equipment and supplies help- sampled for a postpartum interview were different from those who

Downloaded from https://academic.oup.com/intqhc/article/30/7/537/4957982 by Seeley G. Mudd Library user on 26 November 2024

ing to drive and support practice change at facilities. had delivery observation. However, in two hospitals, a total of 10
women (5 in each hospital) who had a delivery observation also
received a postpartum interview, allowing mothers’ responses to be
Evaluation of outcomes compared with observed delivery room practices. This was done to
The primary outcomes were evidence-based clinical practices includ- validate the reliability of mothers’ self-report of delivery practice.
ing: intrapartum (partograph completion [27], episiotomy and aug-
mentation of labor); immediate newborn (early drying, use of sterile Data management and analysis
gloves for cord cutting, time to cord clamping, early skin-to-skin Data were extracted for clinical practices assessed in both the 2008
contact, early initiation of breastfeeding, duration of first breast- and 2015 assessments. Practices that were measured as continuous
feed); and early post-delivery periods (delayed bathing until >6 h variables (timing of drying, cord clamping, breastfeeding initiation
after birth as per national protocol, dry cord care, no bottle feeding, and bathing) in the 2008 assessment were converted to categorical,
and hepatitis B vaccination within 24 h). In 2008, the national pol- ordinal (breastfeeding initiation and bathing) or interval (cord clamp-
icy was that newborns should not be bathed until at least 6 h after ing) variables to align with how the practices were measured in the
birth. This policy was changed to at least 24 h after birth to be con- 2015 assessment. Percentages were calculated for all variables, except
sistent with revised WHO recommendations in 2013 [28]. Since the for duration of breastfeed, total annual deliveries and total live births
6-h bathing policy was in place at baseline and across the study peri- for which medians and interquartile ranges (IQR) were calculated.
od, this was used for pre-post-study comparisons. Differences were compared using Fisher’s exact test or Chi-squared tests
The 2008 assessment used observational methods to collect prac- for categorical, ordinal and interval variables and Wilcoxon rank-sum
tice data [13]. At randomly selected hospitals, trained assessors test for medians. For the 10 mothers interviewed whose deliveries were
observed 10 consecutive births across a 24 h period and documented also observed in the 2015 assessment, the Kappa measure for inter-rater
the minute-by-minute sequence of events and interventions prior to
agreement was used. Data were analyzed using the Intercooled Stata
and until the first hours after birth and rooming-in. Given the lim-
13.0 statistical package (StataCorp, College Station, Texas).
ited knowledge of evidence-based newborn care practices in 2008
and that hospital staff were unaware of the clinical practices being
observed, observation bias was of minimal concern. However, with Ethical issues
the intensive support provided to hospitals since 2010, observation Consent to undertake the assessments was secured from management
bias was considered important in the 2015 assessment design. in each hospital and from the DOH. Ethical review and clearance
Therefore, in addition to observations of delivery practice, exit inter- was not sought for the 2015 assessment as the DOH classified it as a
views and patient chart reviews of postpartum mothers were done programmatic review of routine management practices of trained
using standard checklists [29]. In each hospital sampled in 2015, professionals. The assessment did not influence the time or place of

Table 1 Comparison of baseline statistics, 11 hospitals assessed in both 2008 and 2015 and 39 hospitals (with available data) assessed in
2008 only

Indicators—2008 data 11 Hospitals included in 2008 and 2015 assessments 39 Hospitals included in 2008 assessment only P-value
Median (IQRa) Median (IQR)

Total annual deliveries 6751 (3869–7768) 2959 (2065–4172) <0.001

Total live birthsb 6650 (3760–7160) 2919 (1821–4296) <0.001
% (n/Nc) % (n/N)
Cesarean sectionsd 23.1 (18 080/78 130) 24.7 (21 447/86 778) <0.001
Total low-birth-weight birthse 12.6 (10 175/80 721) 6.6 (2257/34 391) <0.001
NICUf admissionsg 26.0 (17 355/66 640) 15.2 (7261/47 674) <0.001
Neonatal deathsh 2.5 (1774/71 408) 2.0 (1677/83 922) <0.001

a
IQR = interquartile range.
b
Data available for 32 of 39 hospitals assessed in 2008 only.
c
n = numerator, N = denominator.
d
Data available for 27 of 39 hospitals assessed in 2008 only and for 10 of 11 hospitals assessed in both 2008 and 2015.
e
Data available for 13 of 39 hospitals assessed in 2008 only.
f
NICU = neonatal intensive care unit.
g
Data available for 15 of 39 hospitals assessed in 2008 only and for 9 of 11 hospitals assessed in both 2008 and 2015.
h
Data available for 28 of 39 hospitals assessed in 2008 only and for 10 of 11 hospitals assessed in both 2008 and 2015.
Newborn care in the Philippines • Quality improvement 541

deliveries or staff responsible for care, require deviations from cord (from 100% to 3%, P < 0.001), and early bathing before 6 h
accepted clinical practices, and imposed no significant additional bur- of birth (from 92% to 5%, P < 0.0001).
den on patients, families or staff. Informed verbal consent was
secured prior to maternal interviews, and no personal identifiers used
in both assessments. Women who delivered stillbirths or whose new- Discussion
borns died were excluded. Data were used immediately to provide
feedback to facility staff and managers. For similar reasons, the Main findings
DOH did not require ethical review for secondary use of both data- Newborn care practices significantly improved in the 11 hospitals
sets for this manuscript. between 2008 and 2015, including immediate drying, STS contact,
delayed cord clamping, timing and duration of breastfeeding, dry cord

Downloaded from https://academic.oup.com/intqhc/article/30/7/537/4957982 by Seeley G. Mudd Library user on 26 November 2024

care and delayed bathing. Declines of 11–12% were noted in hygienic
Results cord handling and hepatitis B vaccine birth doses. For intrapartum
The 11 hospitals selected for baseline and follow-up comparison care, only antepartum use of oxytocin for labor declined. Validation of
were compared to 39 of 40 hospitals randomly selected in the 2008 exit interview responses with observations showed high levels of agree-
assessment (data were not available for one hospital). The 11 hospi- ment of at least 90% for categorical parameters.
tals included in the comparison study had significantly higher num-
bers of annual births and higher proportions of low-birth weight
babies, and neonatal intensive care unit admissions and deaths, com- Interpretation
pared with the other hospitals sampled in 2008 but not included in
Taken together, these findings suggest that the process of defining a
the study (Table 1). Rates of cesarean section deliveries were signifi-
standard package of EINC, practice-based training, formation of multi-
cantly lower in the 11 hospitals included in the comparison study.
disciplinary hospital teams, periodic assessments and weekly meetings
with actions to improve hospital practices, policies and environments,
Sample have improved newborn care practices in larger hospitals.
A total of 107 mother–baby pairs were observed across 11 hospitals in The demonstrated improvement in facility-based newborn care is
2008, with a minimum of five observed in each hospital. In 2015, a validated by findings of nationally representative population-based
total of 106 mothers were interviewed, their patient charts reviewed surveys in 2008 and 2013, which showed that the proportion of
and 41 deliveries observed. One hospital had no deliveries and another facility-born babies placed in STS contact rose from 10% to 64%
hospital only two deliveries during the assessments in 2015. [13, 30]. During the same period, the fraction of women delivering
at a health facility rose from 41% to 61% and newborn mortality
declined from 16 to 13 per 1000 live births while post-neonatal and
Validation of practices reported on exit interview 1–4 year-old mortality and maternal mortality rates remained static
Observed delivery practices were compared with mother-reported prac- [13, 30]. These findings make it plausible that there was widespread
tices for a subsample of 10 interviewed mothers. One hundred percent institutionalization of immediate STS contact and other evidence-
agreement (K = 1.00) was found for reported time to initiation of STS based newborn care practices across this 5-year period.
contact (whether <10, 11–59 or ≥60 min after birth), duration of Declines in hygienic cord handling and administration of hepatitis
uninterrupted STS contact, completion of first breastfeed before separ- B vaccine birth dose are noted in the 2015 follow-up assessment. Both
ation, reason for separation, ‘rooming-in’ during entire stay and exclu- are supported as part of the EINC practice package. Reports from
sive breastfeeding at discharge. Percentage agreement declined to 90% assessors conducting the 2015 assessment indicate that hygienic cord
(K = 0.84) for whether an episiotomy had been done. handling was often limited by shortages of sterile gloves which
reduced the use of double gloving for delivery. Similarly, reductions in
Appropriate intrapartum and immediate newborn care hepatitis B vaccine birth doses were reported to often be associated
practices with stock-outs of vaccine. These reports highlight the importance of
essential supplies in supporting evidence-based practices; and the need
Most immediate newborn care practices significantly improved
to include these in assessments of quality and for actions to address
between 2008 and 2015 (Table 2). Statistically significant increases
shortages.
were seen in proportions of babies receiving: immediate drying (from
The emphasis of EINC was to improve delivery and newborn
0% to 81%, P < 0.001), delayed cord clamping until after 60 s (from
practices using available staff, space and working environments.
4% to 78%, P < 0.001), STS contact (from 11% to 78%, P < 0.001),
Improvements in most key practices do not require large investments
breastfeeding in the immediate postpartum period (from 56% to
in equipment or supplies. Well-trained midwives and nurses can
95%, P < 0.001), and median duration of the first breastfeed (from
implement most practice changes. This may have contributed to
3 min to 15 min, P < 0.001). Declines were seen in proportions of
increased likelihood of uptake and sustained practice over time. In
babies that had cords handled with clean gloves (from 94% to 83%,
addition, the multi-stakeholder and cross-sectoral approach taken
P = 0.05) and hepatitis B vaccine birth doses (from 94% to 82%, P =
by the DOH with development partners, CSOs and local and
0.01). Partograph completion showed little change and remained low
national government departments supported changes both within
at follow-up.
and outside of the health sector which drove improved care at facil-
ities. These inputs included national policy development, health
Inappropriate intrapartum and newborn care practices financing packages, health facility standards, capacity building from
Between 2008 and 2015, episiotomies decreased insignificantly from tertiary to primary levels of care and health communication. The les-
63% to 54% (P = 0.26). Statistically significant declines were seen sons learned in Philippines informed strategies used in the Regional
in the percentage of deliveries induced or augmented with oxytocin Action Plan for Healthy Newborn Infants in the Western Pacific
(from 27% to 13%, P = 0.01), use of alcohol and iodine on the Region of WHO (2014–2020) with promising results [26, 31–33].
542 Silvestre et al.

Table 2 Change in intrapartum and newborn care practices in 11 government hospitals between 2008 and 2015

Care practice Baseline (2008) % (n/Na) Post-intervention (2015) % (n/Na) P-value

(107 deliveries) (106 deliveries)

Type of delivery
Vaginal 68.2 (73/107) 71.7 (76/106) 0.58
Cesarean section 31.8 (34/107) 28.3 (30/106)
Partograph completed 0.9 (1/107) 5.0 (5/100) 0.11
Episiotomy 63.0 (46/73) 53.9 (41/76) 0.26
Labor induced or augmented with oxytocin 27.1 (29/107) 12.6 (12/95) 0.01

Downloaded from https://academic.oup.com/intqhc/article/30/7/537/4957982 by Seeley G. Mudd Library user on 26 November 2024

Drying initiated within 5 s of birthb 0.0 (0/106) 80.5 (33/41) <0.001
Cord cut using new gloves or by a different attendantb 94.4 (101/107) 82.9 (34/41) 0.05
Time to cord clamping (s)b
0–29 83.0 (88/106) 4.9 (2/41) <0.001
30–59 13.2 (14/106) 17.1 (7/41)
≥60 3.8 (4/106) 78.0 (32/41)
Newborn placed in skin-to-skin contact (%) 11.3 (12/106) 78.3 (83/106) <0.001
Newborn breastfed in immediate postpartum period (%) 56.1 (60/107) 95.3 (101/106) <0.001
Breastfeeding initiation time after birth (min) <0.001
<15 65.0 (39/60) 12.0 (12/100)
15–89 33.3 (20/60) 56.0 (56/100)
≥90 1.7 (1/60) 32.0 (32/100)
Duration of first breastfeed (min)c 3 (1–8) 15 (10–30) <0.001
Hepatitis B vaccine given within 24 h of birth (%) 93.5 (100/107) 82.1 (87/106) 0.01
Substances applied to cord stump (%) 100 (107/107) 2.9 (3/105) <0.001
Newborn bathed early (%) 92.4 (98/106) 4.7 (5/106) <0.0001
Time newborn bathed (h after birth)
<1 99.0 (97/98) 0 (0/26) <0.001
1−6 1.0 (1/98) 19.2 (5/26)
7–24 0 (0/98) 42.3 (11/26)
>24 0 (0/98) 38.5 (10/26)
Newborn fed from a bottle (%) 2.8 (3/107) 0.0 (106/106) 0.25

a
n = Numerator, N = denominator.
b
2015 data obtained from observations of deliveries. N = 41 across 10 hospitals (delivery data from one hospital not available).
c
Measured as median duration of breastfeed in minutes, with interquartile range provided in brackets.

In November 2013, super-typhoon Haiyan devastated central medically indicated. While the training methodology for delivery
Philippines, affecting 13.1 million people, disrupting essential ser- care has been questioned, an assessment of quality of care through
vices and damaging 50–90% of health facilities [34]. Baseline assess- the national Women’s Health and Safe Motherhood Project is pend-
ments (16–22 weeks post-landfall) found that a relatively high ing [37]. The DOH has initiated changes in its Maternal, Newborn,
proportion of deliveries at first-level facilities received key immediate Child Health and Nutrition policies to shift the focus from emer-
newborn care practices [35]. Three months after training cascades, gency readiness towards the provision of integrated essential services
end line assessments demonstrated higher correct partograph use spanning pre-pregnancy, antenatal, intrapartum and postnatal peri-
(54–92%), STS contact (57–84%), breastfeeding initiation ods, with readiness to manage maternal and neonatal complications
(50–86%). These data suggest that by 2013, the national newborn through functional service delivery networks.
care program had already resulted in practice change in this region.
This high level of baseline practice enabled rapid practice improve-
ment post-training after service disruption [35]. Limitations
The lack of improvement in maternal care practices is consistent This secondary analysis is limited to 11 hospitals assessed in both
with assessments done elsewhere in the Philippines [36, 37]. An 2008 and 2015, representing five of 17 regions. These hospitals had
assessment of 95 facilities providing basic emergency obstetric and more deliveries, live births, and higher risk newborns compared to
newborn care (BEmONC) nationwide in 2014 (77% of which were the hospitals assessed in 2008 only. Since the 11 hospitals were
BEmONC accredited rural health units, and 23% primary level hos- selected from the largest hospitals nationwide, they cannot be con-
pitals), found that only four facilities performed all seven signal sidered as representative of care in smaller facilities. When data
functions [36]. The training approach taken for maternal care prac- from the largest maternity hospital in Philippines (purposively added
tices was largely didactic, which may have limited its effectiveness to the 2008 sample) was excluded from the analysis, results did not
[36, 37]. In contrast, the approach used to improve newborn care change significantly, indicating that this hospital did not significantly
through EINC focused on practice-based training and building con- bias findings. As a next step, lower-level hospitals and primary deliv-
ducive facility environments. This approach fosters support of senior ery facilities need to be assessed to determine whether similar prac-
hospital decision-makers and opinion leaders. Several routine intra- tice changes have occurred at this level. In addition, data are needed
partum practices are also addressed, for example position and com- on the impact of observed hospital practice changes on incidence of
panion of choice and elimination of antenatal oxytocin unless newborn sepsis and asphyxia, neonatal intensive care unit
Newborn care in the Philippines • Quality improvement 543

admissions and on newborn deaths, which were not available for all improvements in newborn care have occurred nationwide. The
hospitals included in the sample. Work to improve collection and approach adopted in the Philippines reflected a shift from traditional
use of routine hospital data and death reviews for this purpose is didactic training to training focused on practice, periodic local assess-
ongoing. ments and creation of enabling environments. In addition, the multi-
Women with a stillbirth or neonatal death were excluded from stakeholder and cross-sectoral approach taken by the DOH, supported
the 2015 assessment. Underlying causes of stillbirth are generally changes both within and outside of the health sector which drove
not impacted by EINC interventions and so excluding this group is improved care at facilities. A detailed documentation of strategies that
unlikely to have biased findings [38]. Neonatal deaths may have led to practice change is now needed, alongside a cost-effectiveness
been prevented by EINC interventions (early and thorough drying, analysis.
immediate STS contact, early resuscitation of non-breathing babies)

Downloaded from https://academic.oup.com/intqhc/article/30/7/537/4957982 by Seeley G. Mudd Library user on 26 November 2024

and so excluding this group may miss babies who received sub-
optimal EINC practices. Since newborn deaths represented 2.5% of Funding
all live births in the sample, this potential bias will affect only a low
This work was supported by the WHO which funded the data collection in
proportion of cases and will not change findings significantly.
2008 and 2015. Staff from WHO, DOH and KMI were involved in conceptu-
For the 2015 assessment, one sampled hospital’s delivery room
alization, data analysis and manuscript writing.
was being renovated, and had no deliveries during the assessment per-
iod and one hospital had only two deliveries. Deliveries at these small
hospitals were therefore under-represented in the sample; this may
influence the calculation of cord care practices which require delivery References
observation. All other indicators were obtained from maternal inter- 1. Lawn JE, Blencowe H, Oza S et al. Every newborn: progress, priorities,
views. If cord care practices at these hospitals are significantly different and potential beyond survival. Lancet 2014;384:189–205.
from those with higher case-numbers, then it is possible that this could 2. UNICEF, WHO, World Bank Group, United Nations. Levels and Trends
introduce bias into cord-care practice findings. in Child Mortality Report 2017: https://www.unicef.org/publications/files/
Child_Mortality_Report_2017.pdf Accessed [25 January 2018].
Our cross-sectional design means that data are snapshots of par-
3. Bhutta ZA, Das JK, Bahl R et al. Can available interventions end prevent-
ticular points in time; findings may have varied over time due to a
able deaths in mothers, newborn babies, and stillbirths, and at what cost?
number of unmeasured factors such as staffing patterns or case-
Lancet 2014;384:347–70.
load. The pre-post intervention design risks confounding by secular 4. Mason E, McDougall L, Lawn JE et al. From evidence to action to deliver
trends. No other immediate newborn care interventions took place a healthy start for the next generation. Lancet 2014;384:455–67.
during the period. Furthermore, the vast increases in facility-based 5. Dickson KE, Simen-Kapeu A, Kinney MV et al. Health-systems bottle-
deliveries that have taken place in Philippines between 2008 and necks and strategies to accelerate scale-up in countries. Lancet 2014;384:
2015 have not been offset with increased hospital staff numbers 438–54.
[39]. Since the EINC protocol was the primary DOH effort and sup- 6. UNICEF, WHO. Every Newborn: an action plan to end preventable
ported by national policy directives, it seems most likely to be the deaths: http://apps.who.int/iris/bitstream/10665/127938/1/9789241507448_
eng.pdf?ua=1. Accessed [24 August 2017].
primary influence on health worker practices.
7. Althabe F, Buekens P, Bergel E et al. A behavioral intervention to improve
Finally, there is potential for observational and recall biases.
obstetrical care. N Engl J Med 2008;358:1929–40.
Whilst the 2008 assessment was entirely observational, and there-
8. Spector JM, Agrawal P, Kodkany B et al. Improving quality of care for
fore subject to the Hawthorne effect, bias was considered minimal maternal and newborn health: prospective pilot study of the WHO safe
due to the low knowledge rates of evidence-based practices found at childbirth checklist program. PLoS One 2012;7:e35151.
that time. To minimize observation bias in 2015, exit interviews and 9. Chauhan M, Sharma J, Negandhi P et al. Assessment of newborn care
chart reviews were added. Health facility staff were unaware in corners in selected public health facilities in Bihar. Indian J Public Health
advance of the dates of assessment visits and mothers who had 2016;60:341–6.
delivered in the previous 24–72 h were sampled randomly from 10. Fakih B, Nofly AAS, Ali AO et al. The status of maternal and newborn
postnatal wards, making it unlikely that staff could change practice health care services in Zanzibar. BMC Pregnancy Childbirth 2016;16:134.
11. Bhutta ZA, Salam RA, Lassi ZS et al. Approaches to improve quality of
in anticipation of visits. The sampling method meant that women
care (QoC) for women and newborns: conclusions, evidence gaps and
who had delivered across both daytime and nighttime shifts, with
research priorities. Reprod Health 2014;11:S5.
different health staff, were included, which helped ensure that
12. National Statistics Office (NSO) [Philippines], ORC Macro. National
selected cases were representative of practices under different condi- Demographic and Health Survey 2008. Calverton, Maryland: NSO and
tions. Validation of mothers’ reports showed that recall of events ORC Macro, 2009.
was highly accurate, suggesting that improvements in newborn care 13. Sobel HL, Silvestre MA, Mantaring JBV III et al. Immediate newborn
found here are unlikely to reflect problems of bias or recording. care practices delay thermoregulation and breastfeeding initiation. Acta
Paediatr 2011;100:1127–33.
14. Moore ER, Anderson GC, Bergman N et al. Early skin-to-skin contact for
Conclusions mothers and their healthy newborn infants. Cochrane Database Syst Rev.
2007; (3): CD003519. Review. Update in: Cochrane Database Syst Rev.
This longitudinal observation study used data collected from hospitals
2012; 5: CD003519.
in 2008 and 2015, before and after implementation of a national initia-
15. Gungor S, Kurt E, Teksoz E et al. Oronasopharyngeal suction versus no suc-
tive to improve the quality of delivery and newborn care, to compare tion in normal and term infants delivered by elective cesarean section: a pro-
changes in clinical practices over a 7-year period. The study found sig- spective randomized controlled trial. Gynecol Obstet Invest 2006;61:9–14.
nificant improvements in newborn care practices across 11 hospitals 16. Gungor S, Teksoz E, Ceyhan T et al. Oronasopharyngeal suction versus
nationally. Combined with data from the 2013 nationally representative no suction in normal, term and vaginally born infants: a prospective ran-
population-based survey, this finding suggests that sustained domized controlled trial. Aust N Z J Obstet Gynaecol 2005;45:453–6.
544 Silvestre et al.

17. World Health Organization. Care of the umbilical cord. In: Maternal and 29. World Health Organization Regional Office for the Western Pacific.
Newborn Health/Safe Motherhood. Geneva: World Health Organization, Introducing and Sustaining EENC in Hospitals: Routine Childbirth and
1998. Newborn Care. Early Essential Newborn Care (EENC) Module 3.
18. World Health Organization. WHO Recommendations on Newborn Manila: World Health Organization, 2016.
Health: Guidelines Approved by the WHO Guidelines Review Committee. 30. Philippine Statistics Authority (PSA) [Philippines], ICF International. Philippines
Geneva: World Health Organization, 2017. National Demographic and Health Survey 2013. Manila, Philippines, and
19. Guyatt GH, Oxman AD, Vist GE et al. GRADE: an emerging consensus Rockville, Maryland, USA: PSA and ICF International, 2014.
on rating quality of evidence and strength of recommendations. Br Med J 31. World Health Organization Regional Office for the Western Pacific,
2008;336:924–6. UNICEF. Action Plan for Healthy Newborn Infants in the Western
20. Department of Health Republic of the Philippines, World Health Pacific Region (2014–2020). Manila: World Health Organization, 2014.
Organization Western Pacific Region, UNICEF. Newborn Care until the 32. World Health Organization Regional Office for the Western Pacific.

Downloaded from https://academic.oup.com/intqhc/article/30/7/537/4957982 by Seeley G. Mudd Library user on 26 November 2024

First Week of Life: Clinical Practice Pocket Guide. Manila: World Health Early Essential Newborn Care: Clinical Practice Pocket Guide. Manila:
Organization, 2009. World Health Organization, 2014.
21. Department of Health Republic of the Philippines. Administrative Order 33. World Health Organization Regional Office for the Western Pacific.
2009-0025. Adopting New Policies and Protocol on Essential Newborn Coaching for the First Embrace: Facilitator’s Guide. Early Essential
Care: https://www.scribd.com/document/50591331/AO-2009-0025-Essential- Newborn Care (EENC) Module 2. Manila: World Health Organization,
Newborn-Care [Accessed 24 August 2017]. 2016.
22. Department of Health Republic of the Philippines. Essential Newborn 34. Multi-Cluster/Sector Initial Rapid Assessment: Philippines Typhoon
Care: http://www.doh.gov.ph/essential-newborn-care [Accessed 24 August Haiyan: https://www.wfp.org/content/philippines-typhoon-haiyan-multi-cluster-
2017]. sector-initial-rapid-assessment-november-2013 [Accessed 24 August 2017).
23. Grol R, Grimshaw J. From best evidence to best practice: effective imple- 35. Castillo MS, Corsino MA, Calibo AP et al. Turning disaster into an
mentation of change in patients’ care. Lancet 2003;362:1225–30. opportunity for quality improvement in Essential Intrapartum and
24. Department of Health Republic of the Philippines, World Health Newborn Care (EINC) Services in the Philippines: Pre- to post-training
Organization/Joint Programme for Maternal and Newborn Health, assessments. BioMed Res Int 2016;2016:6264249. http://dx.doi.org/10.
AusAid. Maternal, Newborn, Child Health And Nutrition. Essential 1155/2016/6264249.
Intrapartum and Newborn Care (MNCHN-EINC): Implementation 36. United Nations Development Programme. Consolidated Annual Report on
Manual for Hospitals. For Safe and Quality Care of Birthing Mothers Activities Implemented under the Joint Programme on Maternal and
and Their Newborns. May 2012. Neonatal Health. Report of the Administrative Agent for the Period 1
25. Department of Health Republic of the Philippines. Institutionalization of January—31 December 2014: https://info.undp.org/docs/pdc/Documents/
EINC in Selected Primary Care Facility Settings: Standard Operating PHL/2014%20APR%2090985%20JPMNH.pdf [Accessed 27 August 2017].
Procedures and Forms for Monitoring and Evaluation. Final Technical 37. Republic of Philippines, Department of Health. Women’s Health and Safe
Report. February 2014. Motherhood Project: http://www.doh.gov.ph/womens-health-and-safe-
26. World Health Organization Regional Office for the Western Pacific. First motherhood-project [Accessed 27 August 2017].
Biennial Progress Report: Action Plan for Healthy Newborn Infants in the 38. Reinebrant HE, Leisher SH, Coory M et al. Making stillbirths visible: a sys-
Western Pacific Region (2014–2020). Manila: World Health Organization, tematic review of globally reported causes of stillbirth. BJOG 2018;125:
2016. 212–24.
27. World Health Organization. Integrated Management of Pregnancy and 39. Health Policy Development Program of the UPecon Foundation, Inc.
Childbirth: Managing Complications in Pregnancy and Childbirth: A Guide Part II.7. Ensuring a continuum of care to improve maternal and neo-
for Midwives and Doctors. China: World Health Organization, 2007. natal health. In: The Challenge of Reaching the Poor with a Continuum
28. World Health Organization. WHO Recommendations on Postnatal Care of Care: A 25-year Assessment of Philippine Health Sector
of the Mother and Newborn. Geneva: World Health Organization, 2014. Performance. Manila, 2017: 83–4.