The MDG Challenge for Safe and Quality Care for Birthing Mothers & Newborns

In 2000, world leaders adopted eight Millenium Development Goals (MDGs) for tackling extreme poverty in its many dimensions and seeing results by 2015. The MDGs provide a framework for nations to work together towards a common end making sure that human development reaches everyone, everywhere. Of the 8 goals, Goals 4 and 5 relate to the reduction of child mortality by two-thirds and improvement of maternal health. In the Philippines, 40,000 newborns die in the country each year, from causes that are mostly preventable such as complications of prematurity (41%), birth asphyxia (15%) or severe infection (16%). Most of the deaths occur within the first two days of life, and conditions surrounding labor, delivery and the immediate postpartum period have been pinpointed as contributory factors. Only if measures are instituted to reduce newborn mortality more rapidly can we hope to achieve MDG 4 by 2015. Similarly, the countrys maternal mortality rate has been steadily decreasing since 1990, but at a very slow pace. Maternal deaths are estimated to be close to 5,000 annually. Post-partum hemorrhage continues to be a major cause of maternal mortality (41%). At the current rate of decline, the Philippines is unlikely to reach MDG 5 target of 52 maternal deaths per 100,000 live births by 2015. The Department of Health (DOH) has set into motion a series of responses to address inappropriateness and lack of standardization of immediate newborn care practices. A study was conducted in 2009 among 51 of the largest hospitals in 9 regions in the Philippines using an assessment tool developed by the World Health Organization (WHO) to assesst the state of current birthing practices. Results of the study showed that the performance and timing of evidence-based interventions in immediate newborn care were below WHO standards. In these hospitals, practices prevented Philippine newborns from benefiting from their mothers natural protection in the first hour of life and restricting the performance of these interventions compromised the newborns chance for maintenance of warmth and survival beyond the newborn period. Following the study, a protocol was released on Newborn Care in the First Week of Life Clinical Practice Guide Book. In 2009, DOH began a hospital-based initiative to change practices for safe and quality care of mothers and newborns.1 Supported by the World Health Organization and the Joint Programme on Maternal and Neonatal Health ( JPMNH), the project is being piloted in 11 hospitals and referred to as the Scale Up EINC Project. The project will end in 2011. It is fondly referred to as Unang Yakap 4&5. The challenge now is for the country to narrow the gap by making sure that every mother and every child has the right and access to healthcare from pregnancy through childbirth, the neonatal period and childhood. The Department of Health, Philhealth and international agencies have joined forces, consolidated evidence and formulated policies for an integrated effort to save lives of mothers and their newborns. These guidelines help health professionals and facilities provide safe and quality care for all mothers and their newborns. We cannot stand by and simply watch our mothers die needlessly. Nor is it acceptable that the lives of Filipino children are put at stake because as evidence has shown, the likelihood of children surviving up to their fifth birthday is very closely linked with having mothers that are alive and who are able to care for them. D r. Enrique T. Ona, Secretary of Health, September 2010

Policies for EINC* Care

(Essential Intrapartum & Newborn Care)
Philippine Policies Mandating Safe & Quality Care for Mothers & Their Newborns

MD G
ESSENTIAL INTRAPARTUM AND NEWBORN CARE

To review the policies summarized here, kindly go to www.doh.gov.ph, www.wpro.who.int/philippines, and www.philhealth.gov.ph. And for more information on how EINC Care can be adopted by your hospital or health facility, please write or call your Department of Health Center for Health Development (Regional Office). Or contact the DOH National Center for Disease Prevention and Control Family Health Office at (02) 7329956, (02) 7117846 or trunkline (02) 6517800 local 1726 or email acalibomd@yahoo.com.

DOH Administrative Order 2007-0026 on the Revitalization of the Mother-Baby Friendly Hospital Initiative in Health Facilities with Maternity and Newborn Care Services; AO No. 2008-2029 on Implementing Health Reforms for the Rapid Reduction of Maternal and Neonatal Mortality; and AO 2009-0025 on Adopting New Policies and Protocol on Essential Newborn Care

NATIONAL POLICIES FOR MATERNAL & NEWBORN CARE

The Philippine government, along with the international community, has made legislative efforts to ensure that care of a certain standard is accessible to all mothers and babies.2 The State specifically recognizes the vulnerability of mother and child and demands that measures be enacted to ensure access to care for all mothers and children that is the most current and of the highest standard such that in providing care, the dignity of every mother and child is respected and maintained, and when receiving care, all women and children, regardless of social or economic status, are treated equally. due to preventable causes. This means that time-bound interventions are routinely performed first, non-timebound interventions are performed next, and unnecessary procedures are not performed at all. The four steps to save newborn lives are: immediate and thorough drying of the newborn, early skin-to-skin contact between mother and newborn, properly-timed cord clamping and cutting, non-separation of newborn and mother for early breastfeeding. D. The Aquino Health Agenda: Achieving Universal Health Care for All Filipinos Administrative Order No. 2010-0036 This Order provides objectives, strategic thrusts and implementation framework to implement the Universal Health Care (UHC). The Aquino Health Agenda was launched to improve, streamline and scale up reform interventions. Its main thrusts are financial risk protection, improved access to quality hospitals and health care facilities, and attainment of health-related MDGs. Its core strategies are health financing; service delivery; policy, standards and regulation; governance for health; human resources for health; and health information. The success of the AHA will be measured by the progress made in preventing premature deaths, and reducing maternal and newborn deaths. The goal of the UHC is to ensure that all Filipinos will have equitable access to affordable health care. PPH in preference to other uterotonics (ergometrine/methylergometrine, oral misoprostol, rectal misoprostol or carboprost/sulprostone). Because of the benefits to the baby, the cord should not be clamped earlier than is necessary for applying cord traction in the active management of the third stage of labor. D. Newborn Care until the First Week of Life Clinical Practice Pocket Guide, 2009 The Pocket Guide is a simple, concise and straightforward evidence-based guideline that provides healthcare providers with the ENC protocol focusing on the first week of life. It provides a step-by-step guide to administering a core package of low-cost newborn care interventions that can be administered at all health care settings. It begins with 4 core time-bound interventions that will increase newborn care effectiveness and potentially avert approximately 70% of newborn deaths. These interventions are immediate drying, skin to skin contact followed by clamping of the cord after 1 to 3 minutes, non-separation of the baby from the mother and breastfeeding initiation. Its contents are cross-referenced to equivalent sections within the WHO PCPNC Manual and to other appropriate references.

HEALTH POLICIES FOR ESSENTIAL INTRAPARTUM & NEWBORN CARE (EINC)

The Department of Health has issued directives to ensure the highest quality of care for mothers and their newborns. DOH policies describe methods for providing standard maternal and newborn care to the general population and demand that monitoring and evaluation systems be put in place for these strategies. Similarly, the Philippine Health Insurance Corporation (Philhealth), insists on the importance of safety and quality care that is patient-centered in its hospital accreditation process. The highlights of these policies are:

Philhealth Circulars & Benchbook Guidelines

A. Philhealth Benchbook The Philhealth Benchbook has 7 dimensions for quality health care which guide PHIC standards and performance measures for its accredited hospitals. Hospitals are encouraged to provide a safe, functional and effective environment of care, which includes establishing policies, maintaining a safe and clean environment, providing equipment and supplies identifying and reducing risks of infections, and managing environmental issues. In meeting PHIC Benchbook standards, hospitals are encouraged to always examine how to provide new processes of care based on scientific evidence, clinical standards, cultural values and patient preferences.3 Management is deemed responsible for developing, communicating and implementing a quality improvement program throughout the organization. Through these, the hospital can provide better care and services a result of continuous quality improvement activities. B. New Philhealth Case Rates for Selected Medical Cases and Surgical Procedures and the No Balance Billing Policy Philhealth Circular No. 011-2011 The case rate payment method is introduced for improved efficiency of claims processing and payment to providers. It includes an increased benefit and changes in guidelines for Maternity Care and Newborn Care packages. The policies promote facility-based deliveries and ensure completeness of provision of quality newborn care based on the new DOH and WHO guidelines. The newborn care package covers the following services: immediate drying of the newborn, early skin-to-skin contact, cord clamping, non-separation of mother/baby for early breastfeeding initiation, eye prophylaxis, Vitamin K administration, weighing of the newborn, BCG vaccination, Hepatitis B immunization (1st dose), Newborn Screening Test, Newborn Hearing test and a professional fee that includes breastfeeding advice and physical examination of the baby, among others.

DOH Policies
A. Revitalization of the Mother-Baby Friendly Hospital Initiative in Health Facilities with Maternity and Newborn Care Services Administrative Order No. 2007-0026 This Order aims to guide health workers in revitalize and sustain the mother-baby friendly hospital initiative, to protect, promote and support breastfeeding. It recommends mother-friendly indicators such as positioning during labor and delivery, initiation/skin-to-skin contact in vaginal/abdominal deliveries, minimal use of anesthesia and episiotomies, encourage spouse involvement and/or other family support to a woman before, during and after delivery. The main objective of the policy is to transform all health institutions with maternity and newborn services into facilities that fully protect, promote and support rooming-in, breastfeeding and mother-baby friendly practices. B. Implementing Health Reforms for the Rapid Reduction of Maternal and Neonatal Mortality Administrative Order No. 2008-0029 This Order applies the Fourmula One for Health (F1) approach instituted by then Health Secretary Francisco Duque III for the implementation of an integrated Maternal, Neonatal and Child Health and Nutrition (MNCHN) Strategy. This policy seeks to rapidly reducing maternal and neonatal mortality in the country. This will be achieved through the provision and use of integrated MNCHN services, which refers to a package of services for women, mothers and children that cover known appropriate clinical case management services and cost-effective public health measures which are provided by a service delivery network that is anchored in communities. The MNCHN goal is to improve the functions of health systems and reduce the risks of and prevent direct causes of maternal and neonatal deaths. C. Adopting New Policies and Protocol on Essential Newborn Care Administrative Order No. 2009-0025 This Order outlines specific policies and principles for health care providers with regard the prescribed systematic implementation of interventions that address health risks known to lead to preventable neonatal deaths. It details correct and appropriately-timed interventions in the immediate newborn period that will benefit both the mother and baby as these will avert approximately 70 percent of newborn deaths that are

World Health Organization (WHO) Guidelines

A. Baby Friendly Hospital Initiative: Revised, Updated and Expanded for Integrated Care Section 4: Hospital Self-Appraisal and Monitoring, January 2006 The Baby-friendly Hospital Initiative (BFHI) was launched by WHO and UNICEF in 1991. The initiative promotes practices that protect, promote and support breastfeeding. Different tools and materials were developed, field-tested and provided, including a course for maternity staff, a self-appraisal tool and an external assessment tool. The updated materials integrate code implementation, mother-friendliness, care of pregnant women and mothers in the context of HIV, emergencies as well as expansion towards other type of health facilities and the community. The updated process was also used for strengthening the BFHI-related training courses. B. Pregnancy, Childbirth, Postpartum and Newborn Care: A Guide for Essential Practice Integrated Management of Pregnancy and Childbirth, 2006 This manual aims to provide evidence-based recommendations to guide health care professionals in giving high-quality care during pregnancy, delivery and in the postpartum period, thereby making pregnancy and childbirth safer. All recommendations are for skilled attendants working at the primary level of health care, either at the facility or in the community. They apply to all women attending antenatal care, in delivery, postpartum or post abortion care, or who come for emergency care, and to all newborns at birth and during the first week of life (or later) for routine and emergency care. The PCPNC is a guide for clinical decisionmaking. It promotes the early detection of complications and the initiation of early and appropriate treatment, including timely referral, if necessary. C. WHO Recommendations for the Prevention of Postpartum Hemorrhage, 2006 This guideline contains recommendations reviewed by an expert panel at the Technical Conference on the Prevention of Postpartum Hemorrhage in Geneva in October 2006. The panel considered the following interventions: the active management of the third stage of labor (AMTSL), use of uterotonic drugs, the timing of cord clamping, and the delivery of the placenta by controlled traction, in relation to the outcomes of maternal mortality and morbidity. The major recommendations were: active management of the third stage of labor should be offered by skilled attendants to all women, and they should offer oxytocin for prevention of

Section 11 of Article XIII of the 1987 Constitution, Article XV on the Family and Republic Act 9710 or the Magna Carta of Women. Philhealth Benchbook on Performance Improvement of Health Services., Philippine Health Insurance Corporation, Pasig, 2004