Improving immediate newborn care practices in Philippine hospitals: impact of a national quality of care initiative 2008–2015 (2024)

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Abstract

Introduction

Globally, newborn mortality has fallen at a rate slower than that of older infants and children under five [1, 2]. Consequently, nearly half of all under-five child deaths in low or middle-income countries occur in newborns (0–27 days) [2]. Although a minimum package of cost-effective interventions to reduce newborn mortality has been identified, multiple systems problems limit access to quality care [3–5]. As a response, global partners developed The Every Newborn Action Plan (ENAP) in 2014 [6]. Although small-scale projects have demonstrated improved newborn care, none have been translated into country-level programs [7–10]. Data on improving quality of maternal and newborn 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 initiative to improve the quality of immediate newborn care.

In the Philippines, an estimated 82 000 of 2.4 million children die annually before their fifth birthday with half occurring among newborns [12]. While post-neonatal deaths decreased between 1990 and 2005, neonatal mortality did not [12], thus mirroring the epidemiological pattern found in other low- and middle-income countries [2].

Following a deadly outbreak of early neonatal sepsis in an urban hospital in 2008, an assessment of intrapartum and immediate newborn care in 51 large hospitals revealed inappropriate practices in the 481 deliveries observed [13]. For example, <10% of the newborns received skin-to-skin (STS) contact despite its known benefits [13, 14]. Similarly, 95% of newborns were suctioned unnecessarily [13] despite known risks [15, 16], and substances applied to the cord stump of 99% of newborns despite the global recommendation for dry cord care [17, 18]. A number of other gaps were noted, including immediate cord clamping, early bathing and delayed breastfeeding initiation [13].

As a response, the Philippines Department of Health (DOH), World Health Organization (WHO) and partners developed and adopted a systems approach to improve newborn care practices. We describe this national intervention and findings of hospital care assessments conducted in 2008 and 2015 to investigate whether practices had changed. Quantifying the effectiveness and sustainability of the Philippine approach is crucial for understanding the potential impact of future national programming.

Methods

Study design

This study used data collected from hospitals in 2008 and 2015, before and after implementation of a national initiative to improve the quality of intrapartum and newborn care (essential intrapartum and newborn care—EINC), to compare changes in clinical practices over time. The sampling frame for the 2008 assessment was 150 government hospitals with the highest number of annual births in the Philippines. About 50 hospitals were randomly selected from 9 of 17 regions and the largest hospital in the country exclusively providing maternity services purposively added to give a total of 51 hospitals (methods described in detail elsewhere) [13]. The 2015 assessment included 17 hospitals where EINC was implemented between 2010 and 2015. This sample included all 11 hospitals where EINC was first implemented in 2010 and 2011—‘early implementation hospitals’—and purposive selection of six large hospitals from four regions where scale-up was conducted later in 2012–2015. The availability of clinical practice data from 2008, prior to the intervention, provided an opportunity to conduct a longitudinal observational study to compare trends in practice at the 11 hospitals common to both assessments. Of these hospitals, six were early implementation (2010–2011) and five were later implementation (2012–2015).

National intervention

Figure 1 outlines the process followed to improve quality of intrapartum and newborn care in the Philippines. Between 2009 and 2011, DOH and WHO worked with professional organizations and other stakeholders to review and update newborn clinical practice guidelines using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach to assess quality of evidence [19, 20]. Through this process, a package of evidence-based interventions called EINC was adopted for the Philippines. DOH then issued updated policies [21, 22], the Philippine Health Insurance Corporation revised their newborn package based on the guidelines and updated newborn care standards were integrated into midwifery, nursing and medical preservice curricula and licensure exams.

Clinical training and quality improvement methodologies targeting health worker practice gaps were applied first in 11 government hospitals (9 national and regional, 1 city and 1 university affiliated) [23, 24]. A job aid based on the updated DOH newborn clinical practice guidelines [18, 20] including time-bound, step-by-step care of breathing and non-breathing babies and handwashing tasks was developed. Checklists were used by third party physician assessors to observe at least 10 deliveries and document labor, delivery and immediate newborn care practices. Intensive practice-based training for hospital staff was tailored to address identified practice gaps. Brief interactive didactics were enhanced with coached return demonstrations in classroom 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, multidisciplinary working groups including senior hospital managers, nursing, obstetric, neonatal, anesthesiology staff and external experts met weekly to address barriers and solutions to evidence-based practice, focusing on revising hospital environments to enable practice change. Periodic clinical assessments using checklists were done. Actions undertaken by hospital working groups to address barriers to evidence-based practices and gaps identified from clinical assessments included revising hospital policies, standard operating procedures, health worker roles and physical set-ups for deliveries. When necessary, time–motion studies identified delays in provision of care.

An EINC implementation manual was developed based on the methodology (clinical training followed by a quality improvement process) used in the early implementation hospitals. [24, 25]. The manual was used for national scale-up between 2012 and 2015 at both hospitals and primary delivery facilities by DOH facilitators in collaboration with Kalusugan ng Mag-Ina (KMI), a local non-governmental organization (NGO) with support from various partners.

By the end of 2015, over 14 000 health workers in 252 hospitals had been trained in the EINC quality improvement approach [26]. Broader institutionalization of and demand for EINC was promoted through national health professional associations which collaborated to disseminate information, conduct training and increase awareness among health workers, as well as civil society organizations (CSOs) and NGOs which implemented social marketing activities to promote EINC and breastfeeding in communities through social media and women’s support groups. In addition, national government departments such as the Department of Social Welfare and Development incorporated EINC into family development counseling for the poorest families. Economic planning, finance and budget ministries ensured budget allocation to support maternal and newborn health at national agencies and local government units, and inclusion in national medium and long-term development plans. Local government units, in turn, allocated budget lines to support facility infrastructure, equipment and supplies helping to drive and support practice change at facilities.

Evaluation of outcomes

The primary outcomes were evidence-based clinical practices including: intrapartum (partograph completion [27], episiotomy and augmentation of labor); immediate newborn (early drying, use of sterile gloves for cord cutting, time to cord clamping, early skin-to-skin contact, early initiation of breastfeeding, duration of first breastfeed); and early post-delivery periods (delayed bathing until >6 h after birth as per national protocol, dry cord care, no bottle feeding, and hepatitis B vaccination within 24 h). In 2008, the national policy was that newborns should not be bathed until at least 6 h after birth. This policy was changed to at least 24 h after birth to be consistent with revised WHO recommendations in 2013 [28]. Since the 6-h bathing policy was in place at baseline and across the study period, this was used for pre-post-study comparisons.

The 2008 assessment used observational methods to collect practice data [13]. At randomly selected hospitals, trained assessors observed 10 consecutive births across a 24 h period and documented the minute-by-minute sequence of events and interventions prior to and until the first hours after birth and rooming-in. Given the limited 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 the intensive support provided to hospitals since 2010, observation bias was considered important in the 2015 assessment design. Therefore, in addition to observations of delivery practice, exit interviews and patient chart reviews of postpartum mothers were done using standard checklists [29]. In each hospital sampled in 2015, 2–7 consecutive deliveries were observed on the day of the assessment visit and up to 10 postpartum women who had delivered in the previous 24–72 h selected from admission registers using systematic random sampling for a maternal interview and patient chart review. Mothers with a stillbirth or early newborn death were excluded for ethical reasons. The interview included information on intrapartum and newborn care from the mothers’ narration of their birth experiences. The patient chart review included data on clinical practices that could not be reliably reported by the mother. Women sampled for a postpartum interview were different from those who 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 compared with observed delivery room practices. This was done to validate the reliability of mothers’ self-report of delivery practice.

Data management and analysis

Data were extracted for clinical practices assessed in both the 2008 and 2015 assessments. Practices that were measured as continuous variables (timing of drying, cord clamping, breastfeeding initiation and bathing) in the 2008 assessment were converted to categorical, ordinal (breastfeeding initiation and bathing) or interval (cord clamping) variables to align with how the practices were measured in the 2015 assessment. Percentages were calculated for all variables, except for duration of breastfeed, total annual deliveries and total live births for which medians and interquartile ranges (IQR) were calculated. Differences were compared using Fisher’s exact test or Chi-squared tests for categorical, ordinal and interval variables and Wilcoxon rank-sum test for medians. For the 10 mothers interviewed whose deliveries were also observed in the 2015 assessment, the Kappa measure for inter-rater agreement was used. Data were analyzed using the Intercooled Stata 13.0 statistical package (StataCorp, College Station, Texas).

Ethical issues

Consent to undertake the assessments was secured from management in each hospital and from the DOH. Ethical review and clearance was not sought for the 2015 assessment as the DOH classified it as a programmatic review of routine management practices of trained professionals. The assessment did not influence the time or place of deliveries or staff responsible for care, require deviations from accepted clinical practices, and imposed no significant additional burden 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 newborns died were excluded. Data were used immediately to provide feedback to facility staff and managers. For similar reasons, the DOH did not require ethical review for secondary use of both datasets for this manuscript.

Results

The 11 hospitals selected for baseline and follow-up comparison were compared to 39 of 40 hospitals randomly selected in the 2008 assessment (data were not available for one hospital). The 11 hospitals included in the comparison study had significantly higher numbers of annual births and higher proportions of low-birth weight babies, and neonatal intensive care unit admissions and deaths, compared with the other hospitals sampled in 2008 but not included in the study (Table 1). Rates of cesarean section deliveries were significantly lower in the 11 hospitals included in the comparison study.

Sample

A total of 107 mother–baby pairs were observed across 11 hospitals in 2008, with a minimum of five observed in each hospital. In 2015, a total of 106 mothers were interviewed, their patient charts reviewed and 41 deliveries observed. One hospital had no deliveries and another hospital only two deliveries during the assessments in 2015.

Validation of practices reported on exit interview

Observed delivery practices were compared with mother-reported practices for a subsample of 10 interviewed mothers. One hundred percent agreement (K = 1.00) was found for reported time to initiation of STS contact (whether <10, 11–59 or ≥60 min after birth), duration of uninterrupted STS contact, completion of first breastfeed before separation, reason for separation, ‘rooming-in’ during entire stay and exclusive breastfeeding at discharge. Percentage agreement declined to 90% (K = 0.84) for whether an episiotomy had been done.

Appropriate intrapartum and immediate newborn care practices

Most immediate newborn care practices significantly improved between 2008 and 2015 (Table 2). Statistically significant increases were seen in proportions of babies receiving: immediate drying (from 0% to 81%, P < 0.001), delayed cord clamping until after 60 s (from 4% to 78%, P < 0.001), STS contact (from 11% to 78%, P < 0.001), breastfeeding in the immediate postpartum period (from 56% to 95%, P < 0.001), and median duration of the first breastfeed (from 3 min to 15 min, P < 0.001). Declines were seen in proportions of babies that had cords handled with clean gloves (from 94% to 83%, P = 0.05) and hepatitis B vaccine birth doses (from 94% to 82%, P = 0.01). Partograph completion showed little change and remained low at follow-up.

Inappropriate intrapartum and newborn care practices

Between 2008 and 2015, episiotomies decreased insignificantly from 63% to 54% (P = 0.26). Statistically significant declines were seen in the percentage of deliveries induced or augmented with oxytocin (from 27% to 13%, P = 0.01), use of alcohol and iodine on the cord (from 100% to 3%, P < 0.001), and early bathing before 6 h of birth (from 92% to 5%, P < 0.0001).

Discussion

Main findings

Newborn care practices significantly improved in the 11 hospitals between 2008 and 2015, including immediate drying, STS contact, delayed cord clamping, timing and duration of breastfeeding, dry cord care and delayed bathing. Declines of 11–12% were noted in hygienic cord handling and hepatitis B vaccine birth doses. For intrapartum care, only antepartum use of oxytocin for labor declined. Validation of exit interview responses with observations showed high levels of agreement of at least 90% for categorical parameters.

Interpretation

Taken together, these findings suggest that the process of defining a standard package of EINC, practice-based training, formation of multidisciplinary hospital teams, periodic assessments and weekly meetings with actions to improve hospital practices, policies and environments, have improved newborn care practices in larger hospitals.

The demonstrated improvement in facility-based newborn care is validated by findings of nationally representative population-based surveys in 2008 and 2013, which showed that the proportion of facility-born babies placed in STS contact rose from 10% to 64% [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 1–4 year-old mortality and maternal mortality rates remained static [13, 30]. These findings make it plausible that there was widespread institutionalization of immediate STS contact and other evidence-based newborn care practices across this 5-year period.

Declines in hygienic cord handling and administration of hepatitis B vaccine birth dose are noted in the 2015 follow-up assessment. Both are supported as part of the EINC practice package. Reports from assessors conducting the 2015 assessment indicate that hygienic cord handling was often limited by shortages of sterile gloves which reduced the use of double gloving for delivery. Similarly, reductions in hepatitis B vaccine birth doses were reported to often be associated with stock-outs of vaccine. These reports highlight the importance of essential supplies in supporting evidence-based practices; and the need to include these in assessments of quality and for actions to address shortages.

The emphasis of EINC was to improve delivery and newborn practices using available staff, space and working environments. Improvements in most key practices do not require large investments in equipment or supplies. Well-trained midwives and nurses can implement most practice changes. This may have contributed to increased likelihood of uptake and sustained practice over time. In addition, the multi-stakeholder and cross-sectoral approach taken by the DOH with development partners, CSOs and local and national government departments supported changes both within and outside of the health sector which drove improved care at facilities. These inputs included national policy development, health financing packages, health facility standards, capacity building from tertiary to primary levels of care and health communication. The lessons learned in Philippines informed strategies used in the Regional Action Plan for Healthy Newborn Infants in the Western Pacific Region of WHO (2014–2020) with promising results [26, 31–33].

In November 2013, super-typhoon Haiyan devastated central Philippines, affecting 13.1 million people, disrupting essential services and damaging 50–90% of health facilities [34]. Baseline assessments (16–22 weeks post-landfall) found that a relatively high proportion of deliveries at first-level facilities received key immediate newborn care practices [35]. Three months after training cascades, end line assessments demonstrated higher correct partograph use (54–92%), STS contact (57–84%), breastfeeding initiation (50–86%). These data suggest that by 2013, the national newborn care program had already resulted in practice change in this region. This high level of baseline practice enabled rapid practice improvement post-training after service disruption [35].

The lack of improvement in maternal care practices is consistent with assessments done elsewhere in the Philippines [36, 37]. An assessment of 95 facilities providing basic emergency obstetric and newborn care (BEmONC) nationwide in 2014 (77% of which were BEmONC accredited rural health units, and 23% primary level hospitals), found that only four facilities performed all seven signal functions [36]. The training approach taken for maternal care practices was largely didactic, which may have limited its effectiveness [36, 37]. In contrast, the approach used to improve newborn care through EINC focused on practice-based training and building conducive facility environments. This approach fosters support of senior hospital decision-makers and opinion leaders. Several routine intrapartum practices are also addressed, for example position and companion of choice and elimination of antenatal oxytocin unless medically indicated. While the training methodology for delivery care has been questioned, an assessment of quality of care through the national Women’s Health and Safe Motherhood Project is pending [37]. The DOH has initiated changes in its Maternal, Newborn, Child Health and Nutrition policies to shift the focus from emergency readiness towards the provision of integrated essential services spanning pre-pregnancy, antenatal, intrapartum and postnatal periods, with readiness to manage maternal and neonatal complications through functional service delivery networks.

Limitations

This secondary analysis is limited to 11 hospitals assessed in both 2008 and 2015, representing five of 17 regions. These hospitals had more deliveries, live births, and higher risk newborns compared to the hospitals assessed in 2008 only. Since the 11 hospitals were selected from the largest hospitals nationwide, they cannot be considered as representative of care in smaller facilities. When data from the largest maternity hospital in Philippines (purposively added to the 2008 sample) was excluded from the analysis, results did not change significantly, indicating that this hospital did not significantly bias findings. As a next step, lower-level hospitals and primary delivery facilities need to be assessed to determine whether similar practice changes have occurred at this level. In addition, data are needed on the impact of observed hospital practice changes on incidence of newborn sepsis and asphyxia, neonatal intensive care unit admissions and on newborn deaths, which were not available for all hospitals included in the sample. Work to improve collection and use of routine hospital data and death reviews for this purpose is ongoing.

Women with a stillbirth or neonatal death were excluded from the 2015 assessment. Underlying causes of stillbirth are generally not impacted by EINC interventions and so excluding this group is unlikely to have biased findings [38]. Neonatal deaths may have been prevented by EINC interventions (early and thorough drying, immediate STS contact, early resuscitation of non-breathing babies) and so excluding this group may miss babies who received sub-optimal EINC practices. Since newborn deaths represented 2.5% of all live births in the sample, this potential bias will affect only a low proportion of cases and will not change findings significantly.

For the 2015 assessment, one sampled hospital’s delivery room was being renovated, and had no deliveries during the assessment period 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 observation. All other indicators were obtained from maternal interviews. If cord care practices at these hospitals are significantly different from those with higher case-numbers, then it is possible that this could introduce bias into cord-care practice findings.

Our cross-sectional design means that data are snapshots of particular points in time; findings may have varied over time due to a number of unmeasured factors such as staffing patterns or case-load. The pre-post intervention design risks confounding by secular trends. No other immediate newborn care interventions took place during the period. Furthermore, the vast increases in facility-based deliveries that have taken place in Philippines between 2008 and 2015 have not been offset with increased hospital staff numbers [39]. Since the EINC protocol was the primary DOH effort and supported by national policy directives, it seems most likely to be the primary influence on health worker practices.

Finally, there is potential for observational and recall biases. Whilst the 2008 assessment was entirely observational, and therefore subject to the Hawthorne effect, bias was considered minimal due to the low knowledge rates of evidence-based practices found at that time. To minimize observation bias in 2015, exit interviews and chart reviews were added. Health facility staff were unaware in advance of the dates of assessment visits and mothers who had delivered in the previous 24–72 h were sampled randomly from postnatal wards, making it unlikely that staff could change practice in anticipation of visits. The sampling method meant that women who had delivered across both daytime and nighttime shifts, with different health staff, were included, which helped ensure that selected cases were representative of practices under different conditions. Validation of mothers’ reports showed that recall of events was highly accurate, suggesting that improvements in newborn care found here are unlikely to reflect problems of bias or recording.

Conclusions

This longitudinal observation study used data collected from hospitals in 2008 and 2015, before and after implementation of a national initiative to improve the quality of delivery and newborn care, to compare changes in clinical practices over a 7-year period. The study found significant improvements in newborn care practices across 11 hospitals nationally. Combined with data from the 2013 nationally representative population-based survey, this finding suggests that sustained improvements in newborn care have occurred nationwide. The approach adopted in the Philippines reflected a shift from traditional didactic training to training focused on practice, periodic local assessments and creation of enabling environments. In addition, the multi-stakeholder and cross-sectoral approach taken by the DOH, supported changes both within and outside of the health sector which drove improved care at facilities. A detailed documentation of strategies that led to practice change is now needed, alongside a cost-effectiveness analysis.

Funding

This work was supported by the WHO which funded the data collection in 2008 and 2015. Staff from WHO, DOH and KMI were involved in conceptualization, data analysis and manuscript writing.

References

© 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: journals.permissions@oup.com

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