EINC BullEtIN

Vol 1 June 15, 2011

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news
Are Newborn Care Practices Done Appropriately within the First Hour of Life?: A Survey on 51 of the Largest Hospitals in the Philippinesa Feature: THE QUIRINO MEMORIAL MEDICAL CENTER EXPERIENCE: Accepting the challenge of change EBM Notes:
The JPMNH Scale Up Project

Documenting Essential Intrapartum Newborn Care (EINC) Practices for Safe & Quality Maternal & Newborn Care

Drop in Maternal and Newborn Deaths Marks 8th week of EINC in General Santos
r. 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. Oco 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. Oco 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, Polomolok etc braved the rains to attend the EINC orientation workshop held
ABOVE: Health professionals in General Santos city attending the second round of EINC Orientation Workshop held last May.

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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unang Yakap Embraces

News

8,962

Healthcare Professionals!
r. 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.

Participants follow Dra Izza Flores lead in proper hand hygiene technique at EINC Training in General Santos City

EINC Scale Up, Oct to May 2011

n=8,962

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 National Center for Disease Prevention and Control Director Dr. Ed Janairo or Family Health Offices Dr. Anthony Calibo on radio and television talk about the benefits of adopting the EINC practices.

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Policy Brief Are Newborn Care Practices Done Properly within the First Hour of life?

A Survey on 51 of the Largest Hospitals in the Philippines

he 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-toskin 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

by Louell L. Sala, MD

Metacards activity determine the level of knowledge and awareness on newborn care practices among health professionals

(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 drying, 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. Note. The Acta Paediatrica article can be downloaded for free via this link: http:// onlinelibrary.wiley.com/doi/10.1111/ j.1651-2227.2011.02215.x/pdf

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QuIRINO

tHE

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%), sepsisand pneumonia (16%), asphyxia (15%)1. The study confirmed that currentpractices 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, according to the study. >>

CENtER

MEDICAl
EXPERIENCE
Feature

MEMORIAl

ccepting the challenge of change

by Monica Feria

Barely one year after adopting the new Essential Newborn Care protocols, QMMC cut newborn deaths by half and achieved a 70% reduction in neonatal sepsis. Doing away with unnecessary procedures in the delivery room also saved the hospital a minimum of P3 million.

he 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 QMMCs pediatrics department and lead ENC trainor, remembers this as the starting point of a whirlwind that in barely one years 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 twoto-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 countrys high incidence

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>> 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 careand 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 DOHs Basic Emergency Obstetric and Newborn care (BEmONC) program.

FEATURE
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 periodsmore 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.

HOSPItAl POlICY

r. 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 timebound Essential Newborn Care (ENC) interventions.

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

In the first quarter of 2009, the QMMCs 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.

Harder to implement were the protocols on not interrupting 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 themselves thought of and agreed on steps to address the problems. >>

StAFF tRAINING AND MANPOWER CONCERNS

ith 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.

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FEATURE
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.

Health professionals undergoing weekly meeting with EINC Team

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

MultIDISCIPlINARY APPROACH, INtERNAl AND EXtERNAl PRESSuRE

HOSPItAl INFRAStRuCtuRE AND SuPPlIES

he 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 babys 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 didnt need new and expensive equipment to implement the changes. They noted the positive effects of the physical changes on work habits.

y 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? Staff 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. >>

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>> 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 toescareful, 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.

FEATURE
Non separation of the newborn from the mother for the first breastfeeding resulted in higher breastfeeding rates on discharge at seven and 28 days
highlighted. The media attention it elicited gave the QMMC a rush.

INItIAl BENEFItS, CONtINuING DRIVE

y 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 mothers 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 >>

SHOWING RESultS: A tAStE OF SuCCESS

hile 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 hospitals 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 skinto-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 Unang Yakap, the QMMC pilot experience was

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>> 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. positive and comfortable.

FEATURE
Summing up QMMCs 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 QMMCs 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.

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.

EBM REVIEWS
by Louell L. Sala, MD

lESSONS AND CHAllENGES AHEAD

r. Vitangcol and the rest of the ENC working group know they cannot let down their guard. There is a fast turnover of staff in the delivery room and the young nurses are still schooled in the old methods. Kailangan tutok talaga (you really have to keep close watch). There is always the danger of backsliding. But its much easier now to keep going. I think its because we get more thank yous from the mothers, she added. I make my rounds in the morning and ask the mothers about their birthing experience. They seem less stressed, more

Dr. Jessamine Sareno giving our GenSan audience a crash course in evidencebased medicine

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

What is Evidence Based Medicine? In a world where information can be achieved with a click of a button and yet can be disorganized and unvalidated, Dr. David Sackett in 1996 introduced the concept of Evidence Based Medicine. Defined as a conscientious, explicit, judicious use of current best evidence in making decisions about the care of individual patient, Dr. Sackett described it as a means of integrating individual clinical expertise with the best available external clinical evidence from systematic research. It was created so that as physicians, we can be up to date with the latest modalities, whether diagnostic, treatment or clinical practice guidelines, but more importantly for better quality of care and utilization of resources. >>

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>> In their book Painless Evidence-Based Medicine, Drs. Antonio Dans,
Leonila Dans and Maria Asuncion Silvestre set forth this definition "EBM is a systematic approach to the acquisition, appraisal and application of research evidence to guide healthcare decisions."2 The EINC Bulletin will look at the respective studies behind the EINC practices, dissect them and provide a short assessment that are sound and evidence - based. But in the end we should always emphasize that you are still the attending physician. After all it is the triad of individual clinical expertise, best external evidence and patient values and expectations that forms the backbone of evidence based medicine. EVIDENCE-BASED PRACtICES FOR INtRAPARtuM AND NEWBORN CARE Enemas During labor The use of enemas during labor is common practice among attending physicians. However, enemas can also cause discomfort for women and increase the cost of delivery. The Systematic Review, which made use of the Cochrane Pregnancy and Childbirth Group trials register, Database of Abstracts of Reviews of Effectiveness, and Medline dated from 1966 to December 2006, by Cuervo et. al in the Clinical Epidemiology unit of the Universidad de Javeriana in Columbia, showed that there were no significant differences in the incidence of lower and respiratory tract tract infections among those who used enema during labor after one month of follow up (2 RCTs; 594 women; relative risk (RR) 0.66, 95% CI 0.42 to 1.04) or newborn children (1 RCT; 370 newborns; RR 1.12, 95% CI 0.76 to 1.67). The authors further concluded that there is not enough evidence to evaluate the use of routine enemas during the first stage of labor. Enemas therefore should only be on a per request basis and not routine. Perineal Shaving It is common practice to perform pubic or perineal shaving before birth in order to lessen the risk of infection especially if there is a spontaneous perineal tear. However in a Systematic Review done by Calibri et al. in Centro Interaziendale in Italy, comparing perineal shaving with that of no perineal shaving, the differences were not significant (odds ratio (OR) 1.26, 95% confidence interval (CI) 0.75, 2.12) with regards to post partum maternal febrile morbidity and perineal wound infection. However in one study from the same review, they found that fewer women who had not been shaved had gram negative bacterial colonization compared with women who had been shaved (OR 0.43, 95% CI 0.20, 0.92). How then can we reconcile this single study from the conclusion of the authors? Surrogate outcomes are those that come from laboratory tests while clinical outcomes are those that are well, clinical. So in effect although the gram negative bacterial colonization is indeed significant, there is still no sufficient Clinical Evidence that it can cause perineal wound infection or post partum febrile morbidity.
Sacket dl., et al. Evidence-based medicine: what is and what isnt. BMJ 1996 January 13; (31217023): 71-2 2 Fr. Dans, Al, Dans LF and Silvestre MA. In Chapter 1. Introduction. Dans, AL, Dans LF and Silvestre MS. Painless Evidence Based Medicine. John D. Wiley and Sons, United Kingdom. 2008.
1

REVIEWS
EBM Reviews in Coming Issues:

Unnecessary suctioning, Fundal Pressure, Position of Choice, skin to skin Contact, Breastfeeding, Companion of Choice and AMTsL.

MEEt tHE tEAM

Editors Dr. Maria Asuncion A. Silvestre Dr. Cynthia Fernandez Tan Managing Editor Marcia F. Miranda Feature Editors Donna Miranda Monica Feria Medical Editor Dr. Louell Sala Medical Contributors Dr. Teresita Cadiz-Brion Dr. Donna Capili Dr. Ma. Lourdes Imperial Dr. Jessamine Sareno Dr. Francesca Tatad-To Dr. Ernesto Uichanco Bulletin Advisors Dr. Anthony Calibo Dr. Ivan Escartin Dr. Mariella Castillo

MDG
ESSENTIAL INTRAPARTUM AND NEWBORN CARE

The publication does not reflect the off icial policy of the Department of Health.

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ESSENTIAL INTRAPARTUM AND NEWBORN CARE