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

Philippine hospitals: impact of a national
quality of care initiative 2008–2015

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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 Paci fic 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
6
Reproductive, 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: sobelh@who.int
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.

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 5 Silvestre et

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-
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-

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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
improved newborn care, none have been translated into country-level
hospitals common to both assessments. Of these hospitals, six were
programs [7–10]. Data on improving quality of maternal and
early imple- mentation (2010–2011) and five were later implementation
newborn care at scale are scarce in countries with limited resources
(2012–2015).
[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
annually before their fifth birthday with half occurring among new- intrapar- tum and newborn care in the Philippines. Between 2009
borns [12]. While post-neonatal deaths decreased between 1990 and 2011, DOH and WHO worked with professional organizations
and 2005, neonatal mortality did not [12], thus mirroring the and other stakeholders to review and update newborn clinical practice
epidemio- logical pattern found in other low- and middle-income guidelines using the Grading of Recommendations, Assessment,
countries [2]. Development and Evaluation (GRADE) approach to assess quality of
Following a deadly outbreak of early neonatal sepsis in an urban evidence [19, 20]. Through this process, a package of evidence-based
hospital in 2008, an assessment of intrapartum and immediate new- interventions called EINC was adopted for the Philippines. DOH then
born care in 51 large hospitals revealed inappropriate practices in issued updated policies [21, 22], the Philippine Health Insurance
the 481 deliveries observed [13]. For example, <10% of the new- Corporation revised their newborn package based on the guidelines
borns received skin-to-skin (STS) contact despite its known benefits
and updated newborn care standards were integrated into
[13, 14]. Similarly, 95% of newborns were suctioned unnecessarily
midwifery, nursing and medical preservice curricula and licensure
[13] despite known risks [15, 16], and substances applied to the
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
including immediate cord clamping, early bathing and delayed
hospi- tals (9 national and regional, 1 city and 1 university affiliated)
breastfeeding initiation [13].
[23, 24]. A job aid based on the updated DOH newborn clinical
As a response, the Philippines Department of Health (DOH),
practice guidelines [18, 20] including time-bound, step-by-step care of
World Health Organization (WHO) and partners developed and
breathing and non-breathing babies and handwashing tasks was
adopted a systems approach to improve newborn care practices. We
developed. Checklists were used by third party physician assessors to
describe this national intervention and findings of hospital care
observe at least 10 deliveries and document labor, delivery and
assessments conducted in 2008 and 2015 to investigate whether
immediate new- born care practices. Intensive practice-based training
practices had changed. Quantifying the effectiveness and
for hospital staff was tailored to address identified practice gaps. Brief
sustainabil- ity of the Philippine approach is crucial for
interactive didac- tics were enhanced with coached return
understanding the poten- tial impact of future national
demonstrations in classroom simulations using inexpensive dolls with
programming.
improvised umbilical cords and delivery room supplies. Particular
attention was paid to discussing evidence on harmful practices, e.g.
delayed breastfeeding initiation and
Methods routine separation of mother–newborn dyads. Over the next 6 months,
Study design multidisciplinary working groups including senior hospital managers,
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
tice, focusing on revising hospital environments to enable practice
the quality of intrapartum and newborn care (essential intrapartum
change. Periodic clinical assessments using checklists were done.
and newborn care—EINC), to compare changes in clinical practices
Actions undertaken by hospital working groups to address barriers to
over time. The sampling frame for the 2008 assessment was 150
evidence-based practices and gaps identified from clinical assessments
govern- ment hospitals with the highest number of annual births in
included revising hospital policies, standard operating procedures,
the Philippines. About 50 hospitals were randomly selected from 9
health worker roles and physical set-ups for deliveries. When neces-
of 17 regions and the largest hospital in the country exclusively
sary, time–motion studies identified delays in provision of care.
providing
 Newborn care in the Philippines • Quality 5

EINC package of interventions developed following review of newborn clinical practice guidelines; Job-aid disseminate

National-level actions
(2009–11)
DoH issues updated newborn care policies
Philippine Health Insurance Corporation revises newborn care package to include EINC
Newborn care standards reflecting EINC integrated in clinical preservice curricula and licensure exams

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Clinical training provided to hospital staff on correct childbirth and newborn care practices
Quality improvement approach introduced in 11 early implementation

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 obs

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

EINC hospital implementation manual developed based on the quality improvement methodology used in the 11 early implementation hospitals and used to support national scal
(2012–15)

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
had been trained in the EINC quality improvement approach [26].
pro- cess) used in the early implementation hospitals. [24, 25]. The
Broader institutionalization of and demand for EINC was promoted
manual was used for national scale-up between 2012 and 2015 at
through national health professional associations which collabo-
both hospi- tals and primary delivery facilities by DOH facilitators in
rated to disseminate information, conduct training and increase
collaboration with Kalusugan ng Mag-Ina (KMI), a local non-
awareness among health workers, as well as civil society organiza-
governmental organ- ization (NGO) with support from various
tions (CSOs) and NGOs which implemented social marketing
partners.
 5 Silvestre et
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 develop-
ment 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 govern-
ment units, and inclusion in national medium and long-term devel-
opment plans. Local government units, in turn, allocated budget
lines to support facility infrastructure, equipment and supplies help-
ing to drive and support practice change at facilities.
Evaluation of outcomes
The primary outcomes were evidence-based clinical practices
includ- ing: intrapartum (partograph completion [27], episiotomy
and aug- mentation 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
breast- feed); and early post-delivery periods (delayed bathing until
>6h after birth as per national protocol, dry cord care, no bottle
feeding, and hepatitis B vaccination within 24 h). In 2008, the
national pol- icy 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 con- sistent with revised WHO recommendations in 2013
[28]. Since the 6-h bathing policy was in place at baseline and across
the study peri- od, this was used for pre-post-study comparisons.
The 2008 assessment used observational methods to collect
prac- tice 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 lim- 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 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 inter- views and patient chart
reviews of postpartum mothers were done using standard
checklists [29]. In each hospital sampled in 2015,
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
Median (IQRa)
Total annual deliveries 6751 (3869–7768)
Total live birthsb 6650 (3760–7160)
% (n/Nc)
Cesarean sectionsd 23.1 (18 080/78 130)
Total low-birth-weight birthse 12.6 (10 175/80 721)
NICUf admissionsg 26.0 (17 355/66 640)
Neonatal deathsh 2.5 (1774/71 408)
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.
2–7 consecutive deliveries were observed on the day of the assess-
ment visit and up to 10 postpartum women who had delivered in
the previous 24–72 h selected from admission registers using system-
atic 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.
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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 clamp-
ing) 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
39 Hospitals included in 2008 assessment only P-value
Median (IQR)
2959 (2065–4172) <0.001
2919 (1821–4296) <0.001
% (n/N)
24.7 (21 447/86 778) <0.001
6.6 (2257/34 391) <0.001
15.2 (7261/47 674) <0.001
2.0 (1677/83 922) <0.001
 Newborn care in the Philippines • Quality
deliveries or staff responsible for care, require deviations from
accepted clinical practices, and imposed no significant additional
bur- 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- borns 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 data- sets 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 hospi-
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- pared with the other hospitals sampled in 2008 but not
included in the study (Table 1). Rates of cesarean section deliveries
were signifi- cantly 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
prac- tices 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 separ-
ation, reason for separation, ‘rooming-in’ during entire stay and exclu-
sive 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
5
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
agree- ment of at least 90% for categorical parameters.
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Interpretation
Taken together, these findings suggest that the process of defining a
standard package of EINC, practice-based training, formation of
multi- disciplinary 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 facil- ities. 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 les- sons 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].
 5 Silvestre et

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
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)

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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
Philippines, affecting 13.1 million people, disrupting essential ser-
vices and damaging 50–90% of health facilities [34]. Baseline
assess- ments (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 improve- ment 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 hos-
pitals), found that only four facilities performed all seven signal
functions [36]. The training approach taken for maternal care prac-
tices 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 con-
ducive facility environments. This approach fosters support of
senior hospital decision-makers and opinion leaders. Several
routine intra- partum practices are also addressed, for example
position and com- panion 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 pend-
ing [37]. The DOH has initiated changes in its Maternal, Newborn,
Child Health and Nutrition policies to shift the focus from emer-
gency readiness towards the provision of integrated essential services
spanning pre-pregnancy, antenatal, intrapartum and postnatal peri-
ods, 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 con-
sidered 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 deliv- ery facilities need to be assessed to determine
whether similar prac- tice 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
 Newborn care in the Philippines • Quality
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
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 observation. All other indicators were obtained from
maternal inter- views. 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 par-
ticular 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 sup-
ported 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 there-
fore 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 condi-
tions. 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
initia- tive to improve the quality of delivery and newborn care, to
compare changes in clinical practices over a 7-year period. The study
found sig- nificant 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
5
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 assess-
ments 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 conceptu-
Downloaded from https://academic.oup.com/intqhc/article/30/7/537/4957982 by guest on 13 July 2022
alization, data analysis and manuscript writing.
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