Process Improvement in NICU

RESUSCITATION OF PRETERM INFANTS IN THE PHILIPPINES: A NATIONAL

SURVEY OF RESOURCES AND PRACTICE
Dean Hayden, Maria Esterlita Villanueva-Uy, Maria Katrina Mendoza, Dominic Wilkinson
ABSTRACT
OBJECTIVE
There is a high incidence of preterm birth in low-income and middle-income countries where
healthcare resources are often limited and may influence decision making. We aimed to explore
the interplay between resource limitations and resuscitation practices for extremely preterm
infants (EPIs) in neonatal intensive care units (NICUs) across the Philippines.
METHODS
We conducted a national survey of NICUs in the Philippines. Institutions were classified
according to sector (private/public), region and level. Respondents were asked about unit
capacity, availability of ventilators and surfactant, resuscitation practices and estimated survival
rates for EPIs of different gestational ages.
RESULTS
Respondents from 103/228 hospitals completed the survey (response rate 45%). Public hospitals
reported more commonly experiencing shortages of ventilators than private hospitals
(85%vs23%, p<0.001). Surfactant was more likely to be available in city hospitals than
regional/district hospitals (p<0.05) and in hospitals classified as Level III/IV than I/II (p<0.05).
the financial capacity of parents was a major factor influencing treatment options. Survival rates
for EPIs were estimated to be higher in private than public institutions. Resuscitation practice
varied; active treatment was generally considered optional for EPIs from 25 weeks’ gestation and
usually provided after 27-28 week’s gestation.
CONCLUSION
Our survey revealed considerable disparities in NICU resource availability between different
types of hospitals in the Philippines. Variation was observed between hospitals as to when
resuscitation would be provided for EPIs. National guidelines may generate greater consistency
of care yet would need to reflect the variable context for decisions in the Philippines.
Ref. Hayden D, Villanueva-Uy ME, Mendoza MK, et al. Arch Dis Child Fetal Neonatal Ed
2020;105:F209–F214.

Process Improvement in Delivery Room

EVIDENCE-BASED INTRAPARTUM PRACTICE AND ITS ASSOCIATED FACTORS
AT A TERTIARY TEACHING HOSPITAL IN THE PHILIPPINES, A DESCRIPTIVE
MIXED-METHODS STUDY

ABSTRACT use of oxytocin and controlled cord traction

BACKGROUND
Evidenced-based practice is a key
component of quality care. However, studies
in the Philippines have identified gaps
between evidence and actual maternity
practices. This study aims to describe the
practice of evidence-based intrapartum care
and its associated factors, as well as
exploring the perceptions of healthcare
providers in a tertiary hospital in the
Philippines.
METHODS
A mixed-methods study was conducted,
which consisted of direct observation of
intrapartum practices during the second and
third stages, as well as semi-structured
interviews and focus group discussions with
care providers to determine their perceptions
and reasoning behind decisions to perform
episiotomy or fundal pressure. Univariate
and multivariate logistic regression were
used to analyse the relationship between
observed practices and maternal, neonatal,
and environmental factors. Qualitative data
were parsed and categorised to identify
themes related to the decision-making
process.
RESULTS
A total of 170 deliveries were included.
Recommended care, such as prophylactic
Ref. Masuda, C., Ferolin, S.K., Masuda, K.  et al.  Evidence-based intrapartum practice and its
associated factors at a tertiary teaching hospital in the Philippines, a descriptive mixed-methods
study.  BMC Pregnancy Childbirth  20,  78 (2020). https://doi.org/10.1186/s12884-020-2778-5.
in the third stage, were applied in almost all
the cases. However, harmful practices were
also observed, such as intramuscular or
intravenous oxytocin use in the second stage
(14%) and lack of foetal heart rate
monitoring (57%). Of primiparae, 92%
received episiotomy and 31% of all
deliveries received fundal pressure. Factors
associated with the implementation of
episiotomy included primipara (adjusted
Odds Ratio [aOR] 62.3), duration of the
second stage of more than 30 min (aOR 4.6),
and assisted vaginal delivery (aOR 15.0).
Factors associated with fundal pressure were
primipara (aOR 3.0), augmentation with
oxytocin (aOR 3.3), and assisted delivery
(aOR 4.8). Healthcare providers believe that
these practices can prevent laceration. The
rate of obstetric anal sphincter injuries
(OASIS) was 17%. Associated with OASIS
were assisted delivery (aOR 6.0), baby
weights of more than 3.5 kg (aOR 7.8),
episiotomy (aOR 26.4), and fundal pressure
(aOR 6.2).
CONCLUSIONS
Our study found that potentially harmful
practices are still conducted that contribute
to the occurrence of OASIS. The perception
of these practices is divergent with current
evidence, and empirical knowledge has
more influence. To improve practices the
scientific evidence and its underlying basis
should be understood among providers.
Insight:
Process Improvement in Delivery Room
EVIDENCE-BASED INTRAPARTUM PRACTICE AND ITS ASSOCIATED FACTORS
AT A TERTIARY TEACHING HOSPITAL IN THE PHILIPPINES, A DESCRIPTIVE
MIXED-METHODS STUDY
While I am currently in my course, we were thought of the Essential Intrapartum and New-born
Care which is an evidenced-based practice wherein the quality of care is a focus area for
improvement to reduce avoidable mortality and morbidity in mothers and new born babies.
Even though with the use of EINC, the overall study found out four significant gaps between
intrapartum practice and recommended evidence-based guidelines: a lack of FHR monitoring,
improper use of oxytocin during labour, excessive use of episiotomy for primiparae, and
application of fundal pressure, which I have observed also during my clinical exposure in the
birthing centre. With those unreasonable practices derived from the study, merely disseminating
guidelines and recommendations is unlikely to improve practices, as quality of care will not be
ensured. Scientific evidence and its underlying anatomy, physiology, and pathology should be
well understood among providers. It is particularly important for a teaching hospital to apply
national standards, since its practices are reproduced as the best practices for professionals at
multiple levels of health facilities. Therefore, a continuous training mechanism with relevant
monitoring and supervision should be mandated to ensure quality practices.
Recommended practices for newborn care are time-bound interventions at the time of birth and
elimination of unnecessary interventions. Whereas the country-wide effort resulted in an
improvement of newborn care practices, inappropriate maternal care practices persisted at
tertiary level hospitals according to an evaluation of EINC practices. The effectiveness of
didactic training approaches for maternal care were questioned in this study; however, the
reasons and context behind the poor compliance with guidelines were not well explored.
Therefore, this study aims to describe the practice of evidence-based intrapartum care and its
associated factors, as well as exploring the perception of healthcare providers in a tertiary
teaching hospital in the Philippines.
INSIGHT:

Process Improvement in NICU

RESUSCITATION OF PRETERM INFANTS IN THE PHILIPPINES: A NATIONAL
SURVEY OF RESOURCES AND PRACTICE
In our country, we all know that some of our health facilities are not enough which is one of the
problems faced by Philippines. But many professional organisations and societies have
developed management guidelines to support clinicians facing decisions about offering or
withholding resuscitation for extremely preterm infants. This study means to asses both
availability of neonatal intensive care unit resources and resuscitation practices of preterm
infants across the entire low-income or middle-income country, just like Philippines.
The study surveyed, and with the first requested information in the characteristics of the hospital
including numbers of overall and preterm births. Second, focused on availability of resources
including number of beds, mechanical ventilators and surfactant. Lastly, the information about
hospital policies and practice relating to resuscitation of EPIs. Respondents were also asked how
often resuscitation would be provided for infants born at a given gestation since, there are no
available guidelines that provide specific advice to clinicians in low-income or middle-income
country while incorporating considerations of resource constraints. Studies from these settings
have shown significant variation in resuscitation practices between and within countries.
In many countries, professional organisations have developed guidelines for the perinatal care of
extremely preterm infants (EPIs), including when resuscitation should or should not be provided.
The vast majority of preterm births globally occur in low-income and middle-income countries
(LMICs), where resources limit can affect the provision of medical care. To our knowledge,
there are no published national guidelines for clinicians resuscitating preterm infants in these
settings. Several studies have examined practice in individual hospitals or regions in LMICs,
indicating variation between and within countries in the GA and birth weight verges used for
resuscitation.
We can also see the difference of a private hospital from the tertiary ones. Respondents from
higher level hospitals answered the survey that they do have a larger number of beds and
ventilators. While with private hospitals, public hospitals reported a significantly higher number
of births and preterm births, a larger number of beds but a lower number of ventilators per 100
preterm births. Most hospitals reported experiences of limitations in available ventilators at least
some of the time.
In conclusion, the survey revealed considerable discrepancies in NICU resource availability
between different types of hospitals in the Philippines. Variation was observed between hospitals
as to when resuscitation would be provided for EPIs. National guidelines may generate greater
consistency of care yet would need to reflect the variable context for decisions in the Philippines.