WHO-Western Pacific Region:

Howard Sobel MD, MPH, Reproductive, Maternal, Newborn, Child and Adolescent Health Programme Coordinator

Viet Nam:

Dr. Duong Thi Hai Ngoc, Maternal and Child Health Department, Ministry of Health;

Dr Hoang Tran, Da Nang Hospital for Women and Children

Philippines:

Dr Anthony Calibo, Newborn Care Program Manager, Department of Health

Translating Evidence into Country Action 10-12 April 2015

Source: China other NS, Cambodia DHS 2000-2014, Lao PDR 2000,2006 MICS, 2011 LSIS; Philippines 1993-2014 DHS, FHS, PNG: DHS 1996 & 2006 , Viet Nam, 1997 & 2002 DHS, 2000, 2006, 2011 MICS

Trends- Deliveries assisted by trained health staff

Major causes of death in neonates and children under-

five in the Western Pacific Region - 2012

Source: WHO. Global Health Observatory (http://www.who.int/gho/child_health/en/index.html)

Neonatal deaths: 56%

Every 2 minutes, 1 newborn dies in the Western Pacific Region

231 000 neonatal deaths in the Western Pacific Region every year

1 represents 100 neonatal deaths WHO Global Health Observatory, 2011

Source: Sobel, Silvestre et al, Acta Paediatrica (2011), Philippines

Philippines: documenting the problem

If this benefits babies,

Skin-to-Skin Contact Separated from mother

Why is this so common?

Immediate drying, delayed cord clamp

Immediate cord clamp, delayed drying, suction

Presenter

Presentation Notes

To derive the maximum benefit for newborns, the immediate newborn care interventions should be delivered not just as a package of interventions, but sequenced methodically. These time-sensitive interventions should not be preempted nor undermined by other interventions. Now we know that the evidence is solid, and the following newborn care practices will save lives (ask audience to read aloud with you): Immediate and Thorough Drying Early Skin-to-Skin Contact Properly-timed Cord Clamping Non-separation of the Newborn from the Mother for Early Breastfeeding Unang Yakap. Yakap ng Ina. Yakap ngBuhay.

All

At Risk

First Embrace

Preterm and Low Birth Weight

Sick Newborns

Intrapartum Care Newborn Care

• Labour Monitoring (Partograph) • Intrapartum care

Preterm Labour

• Drying • Skin-to-skin contact • Clamping and cutting the cord appropriately • Initiating exclusive breastfeed

Routine care – eye care, vitamin K, immunizations, weighing and examinations afterwards

• Eliminate unnecessary inductions &C-section

• Antenatal steroids • Antibiotics for

pPROM

• Kangaroo Mother Care • Breastfeeding support • Immediate treatment of suspected infection

Obstructed/Prolonged Labour, Foetal Distress

• Assisted delivery • C-section

Not breathing at birth • Resuscitation

Suspected sepsis • Antibiotic treatment

Benchmark KHM CHN LAO MNG PNG PHL SLB VNM

Newborn situation analysis +++

+++ +++ +++ +++ +++ +++ +++

EENC Action Plan +++

+++ +++ +++ +++ +++ +++ +++

EENC Action Plan costed +++

+ +++ +++ No +++ +++

+++

EENC technical working / coordination group formed

+++ +++ +++ +++ +++ +++ +++

+++

Full-time EENC/newborn MOH focal person identified

+++ No +++ No +++ +++ +++

++

EENC stakeholder group organized to engage political leaders and champions

No ++ +++

No ++ +++ No +

Clinical Protocol adapted +++ No +++ +++ ++ +++ ++ +++

Consensus-building workshop

+++ + +

+

+++

+++ ++ +++

Mechanisms established to ensure professional assoc membership implement EENC

+

No +++

++ +++ +++ No No

WHO-UNICEF scale up readiness (Aug-Nov 2014)

+++ Yes, Done ++ On-going/Partial, + planned no

Regional tools to support countries to change practitioner behaviour

Modules for EENC • National Situation Analysis and

Action Planning • Clinical Practice Pocket Guide • Health Facility Strengthening • Coaching (Facilitator Guide) • Annual Implementation Review and

Planning • Monitoring and Evaluation • Communications: Info kits, promotional

videos, website www.thefirstembrace.org

Viet Nam – Full Speed Ahead

Regional tools to support countries to change practitioner behaviour

Modules for EENC • National Situation Analysis and

Action Planning • Clinical Practice Pocket Guide • Health Facility Strengthening • Coaching (Facilitator Guide) • Annual Implementation Review and

Planning • Monitoring and Evaluation • Communications: Info kits, promotional

videos, website www.thefirstembrace.org

Planning process for EENC • Bottleneck Analysis conducted June-Aug 2013

• Additional pre-plan info collected

May- July 2014

• National consultations on EENC National Action Plan for 2014-2020

Sep 2014 – Jan 2015

• Adoption by MOH • Part of Master Plan on RMNCH Dec 2014

• Mobilizing resources for supporting implementation 2014-2015

Establish Stakeholder Coordination

• MOH and WHO initiated process • Government: MOH, national and regional,

provincial and district hospitals • UN agencies: WHO, UNICEF • INGOs: A&T, Save Children, Plan

International, World Vision • Reproductive Health Technical Group

Current progress • National guidelines on EENC approved by MOH • National Action Plan on EENC developed • Clinical Pocket book adapted • Three Centres of Excellence initiated:

– EENC support team formed – Health staff coached on EENC – Health Facility Strengthening approach introduced

• 124 provincial facilitators trained • About 3000 health staff of provincial level

coached on EENC

Regional tools to support countries to change practitioner behaviour

Modules for EENC • National Situation Analysis and

Action Planning • Clinical Practice Pocket Guide • Health Facility Strengthening • Coaching (Facilitator Guide) • Annual Implementation Review and

Planning • Monitoring and Evaluation • Communications: Info kits, promotional

videos, website www.thefirstembrace.org

Update clinical protocol (July 2014 – April 2015)

• Local expert team established • WPRO pocket book translated into local

language • Technical workshop to review the pocket

book with TA from international consultant • Finalization • Formatting, printing and distributing

Regional tools to support countries to change practitioner behaviour

Modules for EENC • National Situation Analysis and

Action Planning • Clinical Practice Pocket Guide • Health Facility Strengthening • Coaching (Facilitator Guide) • Annual Implementation Review and

Planning • Monitoring and Evaluation • Communications: Info kits, promotional

videos, website www.thefirstembrace.org

Why do traditional training-based approaches not change practice?

• Do not start with understand the larger context • Assume participants have no previous

knowledge; – do not identify & start with health worker beliefs

• Do not change systems in which health workers operate

• Do not affect facility policies which support incorrect or harmful practices

• Do not change attitudes of senior decision-makers, often based on outdated standards

How is coaching different? • 2-day coaching in a delivery room creates

a realistic environment • No lectures • Health workers demonstrate their current

practices unassisted to establish baseline • Facilitators coach participants until

newborn care steps are mastered • Pre- and post-coaching evaluations of

clinical practice, knowledge and hand hygiene ensure participants meet minimum standards

20

Hand Hygiene Pre and Post Tests

• Draw an outline of both hands (front and back) on A4 paper.

• Rub Glow Germ all over hands.

• Wash their hands. • Shine UV Light onto their

hands. • Mark areas with Glow

Germ still present on the hands outlined on the A4 paper.

WHO Western Pacific Regional Office

Checking equipment Setting up newborn resuscitation

area

No more waiting until a non-breathing baby to set up resuscitation area and find leaking equipment 22

Setting up delivery space, dry towel on “bare” abdomen

Left-handers discover it is easier if the equipment is on the left side 23

Dry baby, remove wet cloth, put in immediately in skin-to-skin contact,

and cover with dry cloth

Every participant has to demonstrate supervised drying alone and as part of sequenced actions 24

Clamp and cut the cord once after pulsations stop

No more unnecessary separations and exposure to dirty surfaces needed for “trimming” the cord

25

Counseling mothers on feeding cues

• Babies will be ready to breastfeed when they show the following signs: – Drooling – Mouth opening – Tonguing/licking – Rooting – Biting hands/fingers – Crawling No more forced breastfeeds

26

Practicing Bag and Mask Ventilation for non-breathing babies (after

thorough drying)

Each movement of health workers are examined. Unnecessary movements are eliminated so that chest rise can happen in the “golden minute” 27

Results of Coaching, 6 countries

28

Status of INC coaching in Cambodia (June, 2014)

70% 53%

30% 47%

0%10%20%30%40%50%60%70%80%90%

100%

Referral hospitals Health centers

Staff not trainedStaff trained

Results of Coaching • “Staff usually don’t want to go back to the next day, but they

were excited to continue” -- Viet Nam

• “After practicing the new approach…the babies are stronger, they breathed better than the other approach; they turned pink faster”-- Cambodia

• “The delivery room was quiet”… “The babies were so quite, we were worried. We prodded them to make them cry to make sure they were ok” -- Mongolia

• “Oh, that feels so good, thank you doctor”--Philippines – “That was the first time I was thanked’ --Philippine doctor

• “Thank you doctor for bringing this to my country”—Viet Nam

• “Until this coaching, I thought of newborns as specimens needing things to be done; now I realize they are highly emotional beings…” –Solomon Islands 30

Da Nang Hospital for Women and Children, Viet Nam: Translation of

National and International Guidelines into local action

ĐÀ NẴNG • Surface area: 1257,3km2 • Population: 1 million • Hospital catchment: 10 million • Hospital births:~15,000

Timeline of Events in Da Nang Hospital, Viet Nam

May

• Da Nang Health Department and A&T discussions • Attending EENC WHO/UNICEF workshop • Training key staff

Jun-Jul

•First EENC case for normal delivery 5/7/2014 • Training more staff with A&T financial support •Being trained by WHO and MOH

Aug-Sep

•First EENC case for C-section baby 15/9/2014 •Participating EENC workshops run by WHO and MOH •Establishing official Hospital EENC team •Protocol for EENC in operating room

Oct-Nov

• EENC for all applicable C-section baby 20/10/2014 • Training for staff with A&T financial support • Decree and EENC guidelines from MOH

Jan-Mar

• Training staff with WHO support on health facility strengthening and M&E

• Reinforcement of EENC activities

2014

2015

• 20 hospital staff were trained to be EENC facilitators • EENC facilitators coached

– 185 hospital staff – 86 health professionals from other Da Nang

hospitals – 90 health professionals in Quang Nam Province

• Monitoring trips to Gia Lai, Quang Ngai province

Coaching results and extent in central region

Normal delivery

478

539 489

401 382 334

459

533

468

377 369

305

0

100

200

300

400

500

600

Sep Oct Nov Dec Jan Feb

Total S2S

C-section

877

760 696

741

576

159

671 656 691

546

0

100

200

300

400

500

600

700

800

900

1000

Oct Nov Dec Jan Feb

Total S2S

Outcome

“As compared to the 2 previous C-sections, I found warmer, happier and more satisfied to be with my baby

After C-section for twins

Midwife “We now do not use much resuscitation area as baby and mother are well themselves

Outcome

3.2

5.3

6.8

5.5

2.7 2.5 2.7

5.7

8.3

6.6

0

1

2

3

4

5

6

7

8

9

NICU admission % oflivebirths

Antibiotic use % oflivebirths

Death ‰ of livebirths Exclusive breastfeedingon discharge per 10

babies in neonatal unit

Exclusive breast feedingper 10 randomly babies

in normal nursery

Before EENC After EENC

Gaps found during health facility strengthening process

• High C-section rate • Formula feeding during hospital stay • Short period skin-to-skin for two-thirds

babies with normal delivery • Resuscitation areas not in operating

theatre

Next steps

• Continue regular meetings • Perform monthly exit interview and

observation with checklist • Solve problems • Train staff in hospitals in the regions • Monitor other hospitals • Establish EENC team for the region • Make use of public media • Attract support from all possible sources

Regional tools to support countries to change practitioner behaviour

Modules for EENC • National Situation Analysis and

Action Planning • Clinical Practice Pocket Guide • Health Facility Strengthening • Coaching Session Facilitation • Annual Implementation Review and

Planning • Monitoring and Evaluation • Communications: Info kits, promotional

videos, website www.thefirstembrace.org

Using evidence to inform practice: Health facility data collection in the

Philippines

EENC in the Philippines

• National Action Plan for EENC adopted and costed in 2013

• WPR EENC M&E Framework pilot led by DoH

• Data collection forms sent to facilities implementing EENC

• On-going guidance provided to facilities, visits made

• Data being entered into web-based DHIS 2 or Excel

• Pilot in April & May 2015 Source: Wikipedia map, 2015

EENC in the Philippines

Facilities included in the EENC M&E Framework Pilot

Facility Level Total, #

Implementing EENC, # (%)

EENC facilities included in pilot,

# (%) DOH (National Capital Region)

10 8 (80%) 8 (100%)

DOH Regional 47 39 (83%) 39 (100%) NCR LGU and military hospitals

25 20 (80%) ?

Provincial and Chartered City Hospitals

105 87 (83%) ?

Philippines EENC Coverage Indicators

Coverage measure 2014 Target 2020

% of live births attended by skilled health personnel

72.8% 90%

% of live births that take place at health facilities 61% 90%

% of live births delivered by caesarean section 9.3% 5-15% % of live rural births delivered by caesarean section

7.6% 5-15%

% of newborns breastfed within one hour of birth 49.7% 100% % of live births with a reported birth weight 80.1% 100% % of women who received postnatal care within two days of birth following discharge from facility

70.1%* 80%

% of newborns receiving postnatal care within two days of birth following discharge from facility

52.6% 80%

Source: NDHS 2013 *By skilled providers (doctors, nurses, midwives) only

EENC M&E in the Philippines

Impact Indicators for Newborn Health

Data required

Indicator 2014

Neonatal deaths

Neonatal mortality rate (per 1000 LB) 13 Perinatal mortality (per 1000 LB) 22 Proportional causes of NN death: • Sepsis • Birth asphyxia • Complications of pre-term birth

? ? ?

Prematurity/Low birth weight

Prevalence of low birth weight (<2500g)

21.4%

Prevalence of pre-term birth (< 37 weeks)

2.6%

Source: NDHS 2013

Regional tools to support countries to change practitioner behaviour

Modules for EENC • National Situation Analysis and

Action Planning • Clinical Practice Pocket Guide • Health Facility Strengthening • Coaching Session Facilitation • Annual Implementation Review and

Planning • Monitoring and Evaluation • Communications: Info kits, promotional

videos, website www.thefirstembrace.org

Review & Planning Process • May 2015

• 14 national and sub-national hospitals will be visited to observe practice, review charts & interview mothers and staff

Twelve-Month Detailed Implementation Plan for Early Essential Newborn Care, PHL, 12/3/2013

1. Establish Steering Committee 2. Finalize the Newborn Action Plan 3. Local adaptation of the Clinical

Pocketbook for EENC 4. Health facility strengthening 5. Review and revise pre/in-service

training curriculae 6. Develop EENC information tool kit 7. Implementation review 8. Enforce Milk Code 9. Strengthening MBFHI/accreditation

Activity Actions Responsible Timing 1.Establish Steering Committee

• Develop Terms of Reference. • Agree on membership (proposal: Dr

Bounnack to chair, MCH, Dept Training and Research, Dept Hygiene and Health Promotion, National Hospital representatives (Mitaphap, Sethathirath, Mahosoth, Mother and Newborn Hospital), WHO, CICH, UNICEF, UNFPA, Save the Children, Pediatric Society, Obstetric Society, representatives of midwives, nurses).

• Develop and pass decree. • Monthly meetings; intense follow up

between meetings • Development of timelines, annual

reviews and operational plans.

Somanah Rattana (Terms of reference, membership, frequency of meetings etc)

January 2014 - decree

2.Finalization of the Laos Action Plan for Healthy Newborns (LAP)

• Validation of worksheets on policies and guidelines.

• Develop Zero draft LAP. • Steering committee review of LAP. • Stakeholder review of LAP. • Finalization of the LAP. • MOH adoption of the LAP. • Printing copies

Somanah Rattana Eunyoung Final edited version Approval for draft Print and distribute

January 2013

3.Local adaption of the Clinical Pocketbook for Early Essential Newborn Care

• Presentation of the regional clinical pocket guide (CPG) to Steering Committee.

• Identify sub-group who will work on the local adaptation. • Adaptation by sub-group. • Translation of first draft adaptation. • Visit by Dr. Mianne Silvestre to coordinate final review of

adapted and translated guidelines. • Stakeholder reviews of adapted version. • Report progress to the Steering Committee and finalization of

CPG • Complete translation – back translation – consensus on final

version • Format, produce and print final consensus version

Eunyoung Tiengthong

January – February 2014 final translated version agreed Formatting, printing, production February – April 2014

4.Health Facility Strengthening for EENC

• Identify group who will be responsible for initial work and planning the scale up in 2 national hospitals; get approval from hospital directors

• Field visit to Philippines – EENC sites + implementation training

• Begin process of early implementation into hospitals (Adapt/translate EENC implementation training materials/course guidelines; adapt/translate EENC implementation guide – based on existing PHL version – including monitoring and evaluation indicators; adapt/translate resource person training guide; train hospital teams

Eunyoung Phommady Vesaphong (MCH)

Mahosot ( TBD) J. Murray/M. Silvestre

Oct 6-11- 2-3 staff visit PHL for EENC training and field visits Begin adaptation of EENC implementation materials and guidelines February/March 2014 – June 2014

5. Review and revise pre-service training curriculae and in-service training materials

• Local consultant reviews pre-service curricula and in-service materials

• EENC gaps identified • Consultative process to propose edits/modification • Consensus on modifications needed • Begin process of adapting or modifying curriculae or materials

MOH: Dr. Saiyadeth Local consultant to make edits/changes nd to coordinate review meetings Eunyoung

January 2014 – May 2014 review June 2014 – December 2014 consultative process

6. Develop EENC information tool kit for use by trainers, academic staff in pre- and in-service training

• Map existing materials • Adapt and translate for Lao context • Print and produce materials

Eunyoung WHO/WPRO

Identification, adaption and translation of materials - April 2014 – June 2014

7. Develop social marketing and advocacy approach for EENC and begin implementation

• Develop social marketing approach • Develop messages, materials, media • Begin implementation of social marketing approach

coordinated with hospital implementation

MOH: Eunyoung WHO/WPRO Menzies/Merritt

Approach and materials - May 2014 – onwards Implementation – July 2014 – onwards

8. Conduct EENC program implementation review – early implementation hospitals

• Develop method, materials and indicators • Conduct review • Use data to make program decisions

MOH: J Murray/M Silvestre Eunyoung WHO/WPRO

Method, materials, indicators September 2014 Conduct review – November 2014

9.Strengtheni Code on Marketing of Breast-milk Substitutes

• MOH and UNICEF to lead stakeholders for planning for legislative development.

• MOH-UNICEF drafting of the legislation with participation from WHO + Save the Children

• WHO to support developing briefing materials • ?Role of Ministry of Culture and ?

MOH UNICEF WHO

Regular updates of Steering Committee from UNICEF and WHO 2014

10.Institutionalizing BFHI+ accreditation

• Need inputs from Dr Bounnack what is feasible and how to do it.

Sommana Rattana Discuss with Dr. Bounnack