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MNCHN- Essential Intrapartum & Newborn Care (EINC) Best Practice Forum 30 September 2011

Conference Proceedings SGV Conference Hall (3 rd Floor), AIM Conference Center Manila, Makati City

ESSENTIAL INTRAPARTUM AND NEWBORN CARE MNCHN- Essential Intrapartum & Newborn Care (EINC) Best Practice Forum 30
ESSENTIAL INTRAPARTUM AND NEWBORN CARE MNCHN- Essential Intrapartum & Newborn Care (EINC) Best Practice Forum 30
ESSENTIAL INTRAPARTUM AND NEWBORN CARE MNCHN- Essential Intrapartum & Newborn Care (EINC) Best Practice Forum 30
ESSENTIAL INTRAPARTUM AND NEWBORN CARE MNCHN- Essential Intrapartum & Newborn Care (EINC) Best Practice Forum 30

Table of Contents

PART ONE. BACKGROUND 3 I. INTRODUCTION 3 What are the EINC Practices for the Care of
What are the EINC Practices for the Care of Birthing Mothers &Their Newborns?
IV. Message
By Dr. Enrique T. Ona, Secretary, Department of Health
V. Message
By Dr. Soe Nyunt-U, WHO Representative in the Philippines
VI. Message
By Alexandra Robinson, AusAID
VII. The MNCHN - Essential Intrapartum & Newborn Care (EINC) Project:
The Process of Adopting EINC in Selected DOH Hospitals
By Dr. Maria Asuncion Silvestre, Convener, Team EINC; EINC Consultant, WHO Philippines
VIII. EINC Best Practices from the Scale-Up Project, 2010-2011
A. Antepartal Practices that Save Lives
By Dr. Teresita Cadiz-Brion
B. Early Management of the Parturient in EINC: Walking and Eating During Labor
By Dr. Ernesto Uichanco
C. Mobility, Position and Companion of Choice and Perineal Support During Labor
and Delivery and Active Management of the Third Stage of Labor
By Dr. Cynthia Fernandez Tan
D. Supporting Non-Separation of the Mother-Newborn Dyad in EINC
By Dr. Anna Melissa Francesca Tatad-To
E. EINC in Special Situations
By Dr. Jessamine Sareno
F. Infection Control Practices

By Dr. Fay De Ocampo

  • G. Expanding the EINC Campaign Beyond The Hospital’s Borders:

Service Delivery Networks 20 By Dr. Ma. Lourdes Imperial H. The EINC Self-Instructional Module (SIM) 21
Service Delivery Networks
By Dr. Ma. Lourdes Imperial
The EINC Self-Instructional Module (SIM)
By Dr. Mariella Castillo, WHO Philippines
IX. Forum Discussions
Moderated by Dr. Anthony Calibo, National Center for Disease Prevention and Control
Summary of the Forum
By Dr. Ruben Flores, Medical Center Chief II, Dr. Jose Fabella Memorial Hospital
XI. Moving Forward & Next Steps
By Dr. Teodoro Herbosa, Undersecretary, Department of Health
XII.I Cotabato Regional and Medical Center (CRMC)
XII.II Dr. Jose N. Rodriguez Memorial Hospital (DJNRMH)
XII.III Dr. Jose Fabella Memorial Hospital (JFMH)
XII.IV East Avenue Medical Center (EAMC)
XII.V Eastern Visayas Regional Medical Center (EVRMC)
XII.VI General Santos City Hospital (GSCH)
XII.VII Dr. Jose R. Reyes Memorial Medical Center(JRMMC)
XII.VIII University of the Philippines - Philippine General Hospital (UP-PGH)
XII.IX Quirino Memorial Medical Center (QMMC)
XII.X San Lorenzo Ruiz Women’s Hospital (SLRWH)
XII.XI Tondo Medical Center (TMC)

Essential Intrapartum & Newborn Care (EINC) Best Practice Forum - September 30, 2011

Forum Proceedings Part One: Background

I. Introduction

The Philippines child mortal - ity rate has been assessed to be on track to achieve the MDG4 target of two- thirds reduction by 2015. However, this achievement is threatened by a practi - cally unchanged neonatal mortality rate, since neo - nates account for almost half of all child deaths. 40,000 Filipino newborns die each year, from causes that are mostly preventable, such as complications of prematu - rity, birth asphyxia or severe infection. Most of the deaths occur within the first two days of life.

Essential Intrapartum & Newborn Care (EINC) Best Practice Forum - September 30, 2011 Forum Proceedings Part
Essential Intrapartum & Newborn Care (EINC) Best Practice Forum - September 30, 2011 Forum Proceedings Part

The Philippines’ achievement of MDG 5 looks bleaker. Maternal deaths are estimated to be 162 per 100,000 or close to 5,000 mothers dying annually.

Our national and MDG target of three quarters reduction is 52 maternal deaths per 100,000. Eleven women die daily giving birth, of which post-partum hemorrhage continues to be a major cause of maternal mortality.

Unsafe practices surrounding labor, delivery and the immediate postpartum period were documented in a 2009 landmark observational study of 481 births in 51 hospitals (see bar graph below).

The study magnified the need to step up adoption of critical guidelines in the DOH’s MNCHN Administrative Order and Mother & Baby Friendly Hospital Initiative to address gaps in the delivery and quality of care provided to the mother and newborn dyad.

In the same year, WHO provided technical as - sistance to the DOH in the rigorous guideline development pro - cess of the Essential Newborn Care (ENC) protocol.

DOH Administrative Order 2009-25 on Es - sential Newborn Care was issued in Decem - ber 2009. In 2011, the four core steps of immediate newborn care were included in the revised Philip - pine Health Insurance Corporation (PhilHealth) newborn care package (NCP).

Unsafe practices surrounding labor, delivery and the immediate postpartum period were documented in a 2009 landmark

EINC is a response to gaps in maternal and newborn care: A health systems approach

Since 2010, through the AusAID-supported Joint Program for Maternal and Neonatal Health (JPMNH), WHO is supporting the DOH in using a health systems approach for promoting and institutionalization of evidence-based practices for Essential Intrapartum and Newborn Care (EINC).

DOH support for EINC is in line with Administrative Orders 2007-0026 (Mother-Baby- Friendly Hospital Initiative), 2008-0029 (Maternal, Newborn, Child Health and Nutrition [MNCHN] Strategy), 2009-0025 (Essential Newborn Care [ENC]), and 2010-0016 (Univer - sal Health Care and Aquino Health Agenda) to reduce and stop newborn and maternal deaths by promoting safe and quality care of mothers and their newborns.

The EINC Scale-up Project.

The EINC project began in 2010 in eleven public hospitals where collectively 72,000 women annually give birth. The eleven hospitals are in the National Capital Region (NCR),

the Eastern Visayas and Central Mindanao (SOCCSKSARGEN) regions.

The EINC Scale-up Project. The EINC project began in 2010 in eleven public hospitals where collectively

The DOH -- retained hospitals in NCR:

• Dr. Jose Fabella Memorial Hospital • Dr. Jose R. Reyes Memorial Medical Center • Dr. Jose N. Rodriguez Memorial Hospital • East Avenue Medical Center • Quirino Memorial Medical Center • Tondo Medical Center • San Lorenzo Ruiz Women’s Hospital

DOH-retained Regional hospitals:

• Eastern Visayas Regional Medical

Center (CHD VIII – Eastern Visayas)

• Cotabato Regional and Medical Center

(CHD XII – SOCCSKSARGEN – Central Mindanao)

LGU Hospital

(CHD XII – SOCCSKSARGEN – Central Mindanao)

• General Santos City Hospital

Academic / State University Hospital – in Manila

• University of the Philippines –

Philippine General Hospital

The project is a MNCHN initiative that focuses on the intrapartum period when mothers give birth and where mortality rates are high. The four-pronged approach includes hospital reform initiatives, establishing centers of excellence as models, educational reforms, and social marketing.

In hospitals, the project used a systematic approach with rigorous monitoring and planned transfer of technology to create EINC Centers of Excellence in the eleven hospitals.

Parallel to the hospital scale-up, were efforts for integration in pre-service curriculum and professional licensure requirements as well as the development of innovative training materials for its rapid dissemination.

A social marketing handle for the adoption by practitioners and health facilities of safe and quality care for birthing mothers and their newborns was developed and proved successful. EINC is fondly referred to as “Unang Yakap 4&5,” or “The First Embrace,” in reference to the non-separation that is necessary for the mother and child dyad; all for the achievement of MDG’s 4 and 5.

(IV) fluids that have not been shown to improve maternal nor neonatal outcome. Practices such as routine early amniotomy and oxytocin augmentation have not been shown to have a clear advantage over expectant management. Fundal pressure meant to facilitate the second stage of labor increases the risk of maternal and newborn injuries and even death.

The recommended EINC practices during the intrapartum period include continuous maternal support by having a companion of choice during labor and delivery, freedom of movement during labor, monitoring progress of labor using the partograph, non-drug pain relief before offering labor anesthesia, position of choice during labor and delivery, spontaneous pushing in a semi-upright position, non-routine episiotomy, and active management of the third stage of labor (AMTSL).

What are the EINC Practices for the Care of Birthing Mothers & Newborns?

The EINC practices reflect current


and were developed and

field-tested by international and local experts. They separate the clinical practices for normal deliveries that are necessary or unnecessary for the safe and quality care for birthing mothers and newborns. EINC adoption therefore involves unlearning of old practices and

not just acquisition of new skills.

Essential Intrapartum Care

Unnecessary interventions in the intrapartum period include the routine administration of enemas and shaving, restriction of fluid and food intake during labor and routine insertion of intravenous

Essential Newborn Care

Unnecessary interventions in newborn care include routine suctioning, early bathing, routine separation from the mother, foot printing, application of various substances to the cord, and giving so-called pre-lacteals or artificial infant milk formula or other breast-milk substitutes.

The recommended EINC practices for immediate newborn care are a series of time-bound interventions: immediate and thorough drying of the newborn, early skin- to-skin contact between the mother and newborn, properly-timed cord clamping and cutting, non-separation of newborn and mothers for early breastfeeding initiation.

II. The DOH Maternal Newborn Child Health & Nutrition (MNCHN) Strategy

In 2008, DOH issued an administrative order on Implementing Health Reforms for Rapid Reduction of Maternal and Neonatal Mortality (AO 2008-0029) that proposes that local governments institute an integrated Maternal, Neonatal and Child Health and Nutrition (MNCHN) strategy for delivering health care to families in their communities.

MNCHN aims to rapidly reduce the number of maternal and neonatal deaths in the country. The directive seeks to ensure that 1) Every pregnancy is wanted, planned and supported; 2) Every pregnancy is adequately managed throughout its course; 3) Every delivery is facility-based and managed by skilled birth attendants; and 4) Every mother-and-newborn pair secures proper postpartum and postnatal care with smooth transitions to the women’s health care package for the mother and child survival package for the newborn.

Part Two: Forum Proceedings

II. The DOH Maternal Newborn Child Health & Nutrition (MNCHN) Strategy In 2008, DOH issued an

IV. Message

by Dr. Enrique T. Ona, Secretary, Department of Health, Republic of the Philippines

In four years, our country is set to showcase to the global

community what we have done to achieve the United Nations Millennium Development Goals. We look back to the year 2000 and note that we have given the highest level of commitment to exert government efforts to achieve what was decided in the United Nations Millennium Summit. Right now, we approach that destination and look into ourselves as to how much farther we can set our goals to achieve the impossible.

III. EINC Best Practice Forum Goals and Objectives

The DOH Best Practice Forum was jointly organized by the National Center for Disease Prevention & Control (NCDPC) and the National Center for Health Promotion to share the results of the EINC project and demonstrate practices that support the national goal of meeting its national and global commitments to save newborns and mothers from dying. The technical forum was called a “Best Practice Forum on MNCHN-Essential Intrapartum and Newborn Care (EINC)” and involved leading stakeholders in Maternal & Newborn Health as well as the eleven participating hospitals. It was held on September 30, 2011 from 1:00-8:00 PM at the Asian Institute of Management (AIM) Conference Center, Makati City. In addition to technical papers, poster presentations were done by participating hospitals.

Sadly, the Philippines is not exempt from failing to achieve the MDGs. But, as lives of numerous human beings are at stake, failures are not acceptable. We do our very best, toil at the most critical moments, exhaust all measures and push the limits, sometimes beyond the imaginable so that we can prove to the world that we are one with the international community.

All of these efforts are worth it. Most specially if we know that the beneficiaries of all these are mothers, women in the reproductive age group with special attention to pregnant women and the children – from the newborn to the adolescents.

The Philippines’ maternal mortality ratio and under-5 mortality rate have been glaring statistical eye-openers for all of us. They awaken our consciousness and stir our thoughts to do something about these. Numerous administrative policies, ordinances and legislations have been

enacted and have started to be implemented with the ultimate goal of reducing the number of women and children dying from pregnancy-related complications and number of children dying. The strategies targeting the infant and under-5 age groups will not be enough to sustain the momentum to reduce under-5 child deaths. The attention has now been refocused on the neonates who are the most vulnerable and helpless in their first 28 days of life as they enter our environment and join the healthcare system.

What have we really done and accomplished? It is immaterial under whose regime or administration the distinction or credit will be given to in terms of strategies conceptualized address MDG number 4 and number 5. We have to set aside politics and raise the bar of professionalism and excellence in government service to ensure that we save more lives of mothers and children.

Enhancement Fund ensures that needed facility upgrading and enhancement are made available and prioritized for those facilities providing not just basic and comprehensive emergency obstetric and newborn services, but also essential intrapartum and newborn care.

The Philippine Health Insurance Corporation released its circular on August 5, 2011. Special attention is given to the maternity care package (MCP), the NSD package and the unbundled newborn care package (NCP).

Currently, mobilization of community health teams (CHTs) in areas under the National Household Targeting System (NHTS) are on the way to increase access to quality healthcare services thus ensuring universal health or Kalusugan Pangkalahatan is felt by these communities.

Just like previous administrations, safe and quality healthcare for our mothers and our newborns is one of the commitments of the Aquino administration. This is to ensure that access to universal healthcare for all Filipinos is achieved in line with Kalusugan Pangkalahatan - the Aquino Health Agenda.

Of utmost importance are the poor and disadvantaged families who are deprived of lifesaving measures to improve and save their lives. Apart from being a cornerstone in health sector reform, providing safe and quality healthcare to mothers and their newborns recapitulates the importance that DOH places in achieving the third thrust of our Kalusugan Pangkalahatan – the attainment of the health-related U.N. Millennium Development Goals. We want to reduce child mortality and improve maternal health.

Health facilities all over the country are now receiving utmost attention to improve their health services, medical equipment, sanitation and cleanliness, and patient-centeredness of human resources for health. The Health Facility

  • I should say that we are very fortunate that the Philippines is scaling-up the implementation of the “ESSENTIAL INTRAPARTUM AND NEWBORN CARE (EINC)” protocol. “UNANG YAKAP” is now a by-word among pregnant women and health workers. Unang Yakap, through our technical consultants and officers who have attended international fora in Geneva and Colombo, have received international attention and interest from other health ministries. They have signified future adoption of this knowing that it is evidence-based and the health outcomes are very convincing.

  • I thank you for all of your efforts thus far in providing reliable and competent capacity building activities. These have made an impact not just on health policy and decision making in the participating hospitals but most importantly on countless lives of mothers and newborns that have been saved from unnecessary harm and death.

We now face this challenge. The whole DOH community, its roster of dynamic hospitals, its attached agencies, the pro-active collaboration

of local government units, development partners and other private sector players must forge a sustainable partnership that will further scale-up EINC under the Maternal, Newborn, Child Health and Nutrition (MNCHN) Strategy in areas that have not been reached by the Phase I of the project. Let me remind my DOH family that the MNCHN Strategy should also be scaled- up in its implementation as field experiences validate the need for this to be implemented. Our CHT mobilization campaign will have a strong foundation if the MNCHN Strategy is already grounded well at the grassroots level.

May we all continue to provide unwavering dedication and excellence in the field of public health and hospital administration in pursuit of our goals to lift the lives of Filipino mothers and children!

Ituloy natin ang Unang Yakap tungo sa Tuwid na Landas ng Kalusugan Pangkalahatan!

of local government units, development partners and other private sector players must forge a sustainable partnership

V. Message

by Dr. Soe Nyunt-U, WHO Representative in the Philippines

The little blue pocket guide on “Newborn Care until the First Week of Life” has come a long way.

It was originally

intended to provide authoritative guidance in the care of over two million babies born in the Philippines each year. This initial journey to improve the standard of care in the eleven pilot hospitals (plus some) has become a miniature model to achieving the DOH mandate of Universal Health Care, or Kalusugang Pangkalahatan:

a strengthened health system providing access to quality health care especially to the

poor mother and newborn dyads. This is the story of Essential Intrapartum and Newborn Care (EINC). EINC may well be the “turn- key” solution for the Philippines to rapidly bring down its flat neonatal mortality rate to achieve MDG 4 of a two thirds reduction in child mortality and MDG 5 of a three quarters reduction in maternal mortality ratio.

Universal Health Care requires all people to have access to the basic needed health services without the risk of financial hardship associated with accessing the services. It means providing essential, quality health care, with clear sources of financing. Universal health care especially targets the poor who face physical, financial and social barriers to health access. Universal health care means one standard quality for all and not poor quality care for the poor.

The EINC pilot experience in the past year

has given us a rich harvest of lessons on how the UHC principles, combined with a solid evidence-based standard of practice, results in the institutionalized “embracing” of Unang Yakap in the hospital. This is an embrace that extended to its neighbouring primary care facilities and communities. Unang Yakap translates the UHC principles of equity, quality and safety, efficiency and the right to health into reality. These are manifested by decreases in mortality among

term babies, decreases in neonatal ICU admissions, almost all mothers successfully initiating breastfeeding, real cost savings in institutions, happy and satisfied mothers, happy and well-motivated staff, and hospital- initiated and self-funded efforts to spread the word in their local health network. EINC also served as a logical entry point for quality improvement initiatives such as patient safety and infection control in hospitals. Among the most valuable lessons: the political will for genuine change was vital.

In this rapidly changing health landscape, WHO has sharply refocused its core business towards strengthening health systems to provide equitable access to quality health care especially in efforts to achieve the MDGs. WHO reiterates its commitment of technical cooperation to support the Department of Health’s Universal Health Care agenda across all levels of the health care system, including DOH-retained hospitals, regional Centers for Health and Development and local government units. The challenge for all of us now is this: how to apply the lessons learned from the hospital setting to rapidly create functional regional referral networks providing quality health care for mothers and children. With the EINC experience, we already have a good idea of how to get there.

We congratulate the DOH retained hospitals who will share their experiences in this forum for their openness to change and the remarkable improvements they have achieved in such a short period. We thank our technical consultants, Team EINC for being effective change agents. Together with the Department of Health and our UN family, UNFPA and UNICEF, we sincerely thank AusAID for their generous support for the Joint Program on Reducing Maternal and Neonatal Mortality. Together, we look forward to the achievement of Kalusugang Pangkalahatan for all Filipinos by giving mothers and newborns a healthy start in life.

Mabuhay ang EINC! Mabuhay ang Unang Yakap.

VI. Message

by Alexandra Robinson, AUSAID

It’s a pleasure to be here today. I feel very passionate about these issues. The Government of Australia is committed to assisting the Government of the Philippines

to make progress in meeting its MDG 4&5 goals and I think this initiative makes a very significant contribution.

When WHO explained the initiative to AusAID, it was explained to me that in the first hour of life, there were practices in Philippine hospitals where babies were put on their mother’s breast ten minutes after birth and were unable to suckle. If we could just teach doctors and nurses to keep the baby on the mothers’ breast for at least 15 minutes, this would result in greater impact on how babies breastfeed and would result in a greatly improved outcome in terms of the mothers breastfeeding and for the baby to be able to obtain nutrition in those early days of life and beyond. There were a

number of other messages.

I couldn’t believe

that simply changing attitudes and beliefs could result in such fantastic change, in the Philippines, and I am sure in other countries too.

I’m pleased to know that DOH and WHO went ahead and did implement the project in 11 hospitals. It will be rolled out nationwide and is going to result in better outcomes for mothers and babies in the Philippines. Because, if we can reduce the rate of mothers dying, since even as I speak a Filipina mother dies in giving birth, then we know that all of our efforts are coming to fruition. I really believe that they are. In terms of our funding the joint program, WHO, UNFPA and UNICEF are all working together with different initiatives under one umbrella to assist the Philippines and make the progress that is required. Of which the Department of Health is critical in deciding which initiatives matter the most.

I wish the next phase of this program every success. We will reap the rewards. It is the mothers and children that really deserve to benefit and I am sure they will.

VII. The MNCHN - Essential Intrapartum & Newborn Care (EINC) Project: The Process of Adopting EINC in Selected DOH Hospitals

by Dr. Maria Asuncion Silvestre, FPSNbM, FAAP Convener, Team EINC, EINC Consultant, WHO Philippines

The DOH with support from the JPMNH initially conducted studies to determine the state of implementation of maternal and newborn interventions known to prevent common causes of newborn mortality. This observational study assessed 481 consecutive deliveries in 51 of the largest hospitals in 9 regions representing an estimated 10% of annual live births in the Philippines. Using a delivery assessment tool, the performance and timing of procedures in obstetric and immediate newborn care were found to be below WHO essential newborn care standards. Similar gaps in the quality of services were seen in maternal practices.

The Essential Newborn Care (ENC) Protocol Diversifies into Essential Intrapartum and Newborn Care

The guideline developed ENC Protocol

addresses these gaps from intrapartum care until the first week of life. The Protocol has been condensed into a Pocket Guide for use by health workers. In December 2009, DOH Administrative Order 2009-0025 was signed by then Secretary Duque mandating implementation of the ENC Protocol in both public and private hospitals and the Unang Yakap campaign was launched. Initial experience with ENC Implementation at the

Quirino Memorial Medical Center underscored

the need to partner with obstetricians and

delivery room personnel and drove home the message that training activities alone are not

sufficient. Beyond training workshops, enabling of the policy and physical environment of each facility is imperative.

Scale-up Implementation of Essential Intrapartum and Newborn Care (EINC) in 11 Government Hospitals: The Process and Outcomes

Scale-up Implementation of the EINC Protocol is winding up in 11 government hospitals representing about 3% of all national live births. Since October of 2010, in each of these hospitals, the scale-up process has entailed 1) a baseline situational analysis including delivery assessments, time-motion studies in the delivery areas and NICU, baseline neonatal morbidity and mortality data, 2) saturation training workshops of all hospital staff, 3) a monitoring and evaluation phase consisting of weekly meetings with the hospital EINC Working Group over a minimum of 6 months with repeat assessments and 4) disengagement.

This scale-up process has been very effective in changing practices and impacting on newborn outcomes, specifically reduction in NICU admissions, in term mortality and sepsis and increase in exclusive breastfeeding rates at 7 and 28 day follow-up visits. In addition, improvements are also seen in maternal care and infection control practices, and in reduced workloads and expenses. Breastfeeding initiation rates and duration of the first breastfeed have improved. Simple cost saving computations by different hospitals has revealed substantial savings averaging almost PhP 500 per vaginal delivery.

The impact of implementing EINC has extended beyond achieving clinical excellence and spilled over to improve quality, safety and efficiency of hospital services and patient satisfaction. This reinforces the evidence for offering interventions as a package of services

to increase effectiveness. The package can be implemented within the existing health system even with limited resources initially through facility-based clinical care but with capacity to scale up through outreach and family- community care.

The Scale Up Project had challenges in its implementation. Each site had its unique issues. But overall, it was observed that success in scaling up needed to (1) first, overcome the inertia and resistance to change in the health institution and among health professionals; (2) resolve conflicts of interest, both individual and institutional which could block the needed change in practice; (3) promote adoption of the Guidelines at multiple levels beginning with the hospital administrator and senior staff; (4) adapt, rather than directly seek to promote the adoption of guidelines as each environment has different socio-cultural-economic contexts and (5) for each institution to have its own plan for dissemination and monitoring of the new practices and sharing of the experience to the larger community.

VIII. EINC Best Practices from the Scale-Up Project, 2010-2011

A. Antepartal Practices that Save Lives

by Dr. Teresita Cadiz-Brion, MD, MHPEd, FPOGS

Worldwide, statistics have shown that both the mother and her newborn are most vulnerable during labor, delivery and the immediate postpartum period. Essential Intrapartum and Newborn Care or Unang Yakap 4 & 5 is a set of evidence-based clinical practices that emphasizes non-medicalized rather than technology-driven practices in a facility with skilled birth attendants trained not only in delivery practices but also in care essential for the newborn. EINC offers the comfort and feel of a home birth and the safety of an equipped medical facility.

Provision of a birth plan, use of a partograph to monitor labor and the timely administration of antenatal steroids are antepartal EINC practices that can save the lives of mothers and their babies.

Birth and Emergency Plans

Health workers should help a mother write her

birth plan – a document which embodies her and the baby’s father’s expressed preferences for where she will deliver, means of transport. who the attendant will be, PhilHealth coverage, blood type and potential donors with their contact numbers, etc. This obligates the couple to plan properly and promptly for her delivery. By including Unang Yakap and breastfeeding initiation in the couple’s birth plan, the health worker truly becomes an advocate for the mother-newborn dyad.

Partograph Use

The partograph is a tool used to assess the progress of labor and to identify when intervention is necessary. Studies have shown that using the partograph can be highly effective in reducing complications from prolonged labor for the mother (postpartum hemorrhage, sepsis, uterine rupture and its sequelae) and for the newborn (asphyxia, infection, death). As part of the Safe Motherhood initiative, WHO promotes partograph use with a view to improving labor management and reducing maternal and fetal morbidity and mortality. Partograph use is a simple, affordable and effective approach to reduce intrapartum-related neonatal deaths in low resource settings. When used with defined management protocols, the partograph can effectively monitor labor and prevent obstructed labor.

Antenatal Steroids

Betamethasone or dexamethasone injections to the mother do not increase her risk for death or infection but are life-saving for her premature baby. A single course of antenatal corticosteroids

to accelerate fetal lung maturation in women at risk of preterm birth should be considered routine for preterm delivery with few exceptions.

Unfortunately, these cost-effective life-saving practices are not yet universally performed in the Philippines. We highlight the creative solutions to this problem arrived at in the eleven (11) advanced implementation hospital sites of the EINC scale-up project.

B. Early Management of the Parturient in EINC: Walking and Eating During Labor

by Dr. Ernesto Uichanco

At the QMMC, intravenous sets and IVF in

the OB Normal Kits have been replaced with bottled drinking water and crackers. At the

Dr. Jose N. Rodriguez Memorial Hospital, IV fluids are a rare occurrence, their use restricted to high risk mothers.

Eliminating Routine Intravenous Fluids (IVF)

With women being able to drink and eat during labor, routine IV fluids are no longer

necessary for maternal hydration and caloric needs. Mothers can ambulate more freely and assume their preferred position allowing a more physiologic process.

Previous management of normal pregnant women in labor entailed routinely fasting her (placing her on NPO), routine insertion of an IV line with fluid infusions and restriction of her movement. Discontinuation of such routine practices is being advocated in EINC because these have not been proven necessary in true normal labor and delivery and may, in reality, be inhibiting the more natural and physiologic processes of labor.

Eliminating Routine “Nothing Per Os” (NPO)

One study evaluated the probable risk of maternal aspiration mortality to be in the extremely low range of approximately 7 in 10 million births. For the normal, low risk birth in any setting, there is no need for restriction of food, except in situations where intervention is anticipated. On admission, patients in early or in the Latent Phase of labor are now allowed to take fluids and light meals or easily digested food (such as crackers). Patients in more advanced stages of labor, fluids may still be allowed up till two hours prior to the expected delivery or planned procedure. This allows fulfillment of fluid and caloric needs without necessarily adding any risks to the woman in labor.

There are also potential adverse effects of infusing glucose solutions to the mother i.e. interference with glucose and insulin levels in both the mother and baby. Excessive insulin production in the fetus occurs with high glucose loads during labor and can result paradoxically in low blood sugar levels and build-up of acids in the newborn. Excessive use of dextrose-only salt-free IV solutions can also cause a fall in serum osmolality and low serum sodium levels in both the mother and the fetus. Thus, the use of IV glucose and fluids to prevent or combat ketosis and dehydration in the mother may have serious unwanted effects in both mother and baby.

Regardless of solution type, intravenous therapy does not ensure a nutrient and fluid balance for the demands of labor and predisposes women to immobilization, stress, increased risk of fluid overload. Other reported adverse effects include headache, nausea, slowing of labor and difficulty in establishment of breastfeeding. It is not likely to be beneficial, and no studies have demonstrated that routinely placing an IV in low-risk laboring women prevents poor outcomes.

In more traditional medical centers, like the UP-PGH, where IV access is still deemed to be a necessary precaution even in non-high risk parturients, a “heplock”, without the attached “venoset” and fluids, is inserted. Limiting the freedom of movement. This modification is still under study as only 20 – 30% of the mothers “heplocks” eventually need IV access.

Both of the above EINC practices are being implemented with due consultation with anesthesiologists, who are now recognized as important partners in the implementation of the EINC protocols.

In more traditional medical centers, like the UP-PGH, where IV access is still deemed to be

Encouraging Preferred Labor Position

Another practice that hospitals adopted was to encourage mothers to labor and deliver in a supine position. Evidence shows that the ability of a woman to move around freely during the first stage of labor and take an upright (including squatting) position during the second stage of labor leads to less inter- ventions, a faster delivery, fewer episiotomies, and therefore a mother and child are more able to initiate breastfeeding.

Being upright (sitting on birthing stools or chairs; squatting) or semi-upright has ad- vantages for women delivering their babies. The benefits of upright positioning may be related to gravity, less aorto-vagal compres- sion, improved fetal alignment, and larger anterior, posterior and transverse pelvic outlets. In a Cochrane review on upright vs.

supine positioning, there was a reduction in the incidence of abnormal fetal heart rate patterns and in the need for episiotomies. There was an increase in second and third degree perineal tears, but the incidence of the other morbidities were not found to be significant.

Most delivery room beds are designed for the patients to be in dorsal lithotomy position. To implement the semi-upright position during delivery, patients were propped up using pillows or assisted by nurses and stu- dents. Soon, a wooden wedge was designed and placed on top of the flat DR beds. The hospitals came up with their own designs. In Cotabato, the engineer remodeled six DR beds with different designs.

C. Mobility, Position and Compan- ion of Choice and Perineal Support During Labor and Delivery and Ac- tive Management of the Third Stage of Labor(AMTSL)

by Dr. Cynthia Tan

It is not easy to change labor and delivery practices which have been in place for many years, especially if these practices are convenient to the staff and hospital management. Please see figure on the right. However, every ef- fort must be made to change practices and attitudes to those that are based on good scientific evidence and pro- vide better care to the mother.

Mobility, Position and Companion of Choice and Perineal Support

Women who receive continuous support, are al- lowed to walk, assume semi-upright or side-lying positions that they are comfortable in are more likely to have a spontaneous vaginal birth, are less likely to need pain control, have shorter labor and are less likely to have a cesarean section or have a baby with a low 5-minute Apgar scores. These “soft interven- tions” in obstetric care contribute to the elimination of potentially harmful practices e.g. fundal pressure which when performed without indication can contribute to maternal complications or even death. Perineal support when applied skillfully precludes the need for surgical cuts and prevents lacerations.

Fundal pressure involves using the hands to push on the uterine fundus down toward the birth canal during the second stage of labor. It is done purportedly to help the mother with expulsion of the fetus. The true preva- lence of its use is unknown. It is a controversial obstetric technique that has increased the risk for both maternal and fetal morbidity and mortality.

C. Mobility, Position and Compan- ion of Choice and Perineal Support During Labor and Delivery and

Episiotomy used to be routine practice during delivery to make birth easier for the baby and to protect the mother from trauma to the birth canal. Routine use of episiotomy reduces anterior lacerations but fails to accrue any other maternal or fetal benefits traditionally ascribed to it. It must be used only selectively (e.g. for a big baby, a tight perineum, or when forceps is to be used).

Active Management of the Third Stage of Labor (AMTSL)

AMTSL refers to a sequence of actions performed during the third stage of labor to prevent postpar- tum hemorrhage (PPH). It shortens the third stage of labor by increasing uterine contractions and prevents PPH by minimizing uterine atony. AMTSL components are: 1) administration of an uteroton- ic drug within one minute after the baby is born (oxytocin 10 IU IM is the uterotonic of choice). 2) controlled cord traction (CCT) with countertrac- tion and 3) uterine massage immediately after delivery of the placenta. Manual exploration of the uterus is eliminated and inspection of placenta and its membranes performed instead.

Simple as these changes in practices may sound, time, energy and commitment are needed to unlearn previous behaviors and make changes. In the one-day EINC orientation workshops for doctors, midwives and nurses, hospital staff are told of the beneficial thus necessary, and unnecessary or even potentially harmful interventions. However, oftentimes, training is not enough because the staff need to be encouraged and supported. For example, a hospital memorandum prohibiting fundal pressure was issued, citing the potential harm it could do to mothers and babies. Beyond just training, persistent guidance and monitor- ing resulted in increasing deliveries without episiotomies. Other factors that drive these outdated practices were examined. For ex- ample, training requirements of senior medical

students (clinical clerks) were reviewed. Instead of requiring each clinical clerk ten episiotomies during their 15 day rotation, they were required to handle ten deliveries with perineal support and controlled delivery of the head. A miscon- ception that episiotomies had to be performed in order to get a PhilHealth reimbursement on vaginal deliveries was likewise dispelled.

Weekly EINC meetings were crucial – each week the team devised strategies to be able to fully implement essential intrapartum and newborn care. Needless to say, a strong leadership and an openness to adopt evidence based interventions, one step at a time, is important.

D. Supporting Non-Separation of the Mother-Newborn Dyad in EINC

by Dr. Anna Melissa Francesca Tatad-To

Among the four (4) core steps of Essential Newborn Care, non-separation of the mother and newly born infant is often the most difficult to implement. Traditional practices include removing the infant from the mother for weighing, immediate examination, bathing and the immedi- ate administration of vaccinations, eye prophylaxis and vitamin K; observation of babies in the nursery; and a routine period of separation for babies who were deliv- ered by cesarean section while their moth- ers recover from anesthesia and sedation. Certain hospital policies and protocols created to facilitate these practices may serve as barri- ers to implementation of non-separation.

While baseline and repeat time-motion studies performed at each institution help identify barriers, regular team meetings with

Simple as these changes in practices may sound, time, energy and commitment are needed to unlearn

representatives from all involved departments such as OB-Gyne, Pediatrics, Anesthesiology, Nursing and Hospital Administration, allow for a more in-depth discussion of the challenges to implementation, as well as unified proposals for appropriate solutions. Understanding the routine hospital policies, physical set-up of the

obstetric and newborn care areas and identify- ing the health workers responsible for critical steps are all crucial.

Non-separation is easier achieved in uncomplicated vaginal deliveries, but can also be performed in the majority of cesarean deliveries and healthy preterm infants. Data from our centers of excellence shows that with a center’s full commitment to the program and cooperation from all health care workers involved, over 90% of all newborns can receive the full benefit of EINC, even in hospitals with a large proportion of high-risk deliveries.

obstetric and newborn care areas and identify- ing the health workers responsible for critical steps are

Non-separation recognizes that the mother’s embrace is the ideal environment for the newborn. Therefore the goal is to keep mothers and babies together for as long as possible, and to revise methods of health care delivery that jeopardize this. Some specific practices which improve the implementation of non-separation are 1) review and revision of policies for routine NICU admission 2) observing at-risk but well babies and babies with likely transient symptoms like breathing difficulty while the baby is in skin- to-skin contact rather than admitting directly to the NICU 3) the practice of kangaroo mother care (KMC), which allows small and/or premature but stable infants to be cared for by their mothers and monitored by hospital staff outside the high- risk environment of the NICU.

Full implementation of non-separation contributes to decreased NICU admissions, decreased burden of work on the health care staff, an improvement in overall outcomes and maternal/paternal satisfaction with the birthing experience.

E. EINC in Special Situations

by Jessamine Sareno, MD, DPPS

The Essential Intrapartum and Newborn Care program is driving a paradigm shift in the delivery of maternal and newborn care services in our country. The change process has been set in motion in the 11 hospital scale- up sites that have been co-creating EINC experiences through the past months. These experiences provide a wealth of information on the different strategies to hurdling difficulties in implementation and breaking through the resistance of those wary of deviating from the status quo.

EINC in Cesarean Section and Twin Gestation

When the protocol was initially introduced, most professionals could not envisage doing EINC in Cesarean deliveries. Commonly fielded questions included, “Where will the baby be dried?” “How can we maintain skin to skin contact while the cord is still attached?” “How can we possibly do non-separation?”

obstetric and newborn care areas and identify- ing the health workers responsible for critical steps are

Yes, EINC can be done in Cesarean deliveries. The only difference is that after drying, cord clamping is done before the newborn is placed in skin-to-skin contact with mother. After delivery of the newborn, he/she is positioned in the hollow of the mother’s thighs for thorough drying. After umbilical pulsations stop, the cord is clamped with the sterile plastic clamp and cut. The baby is brought to the mother’s chest area behind the anesthesia screen, either prone across the mother’s chest or longitudinally with baby’s face at the breast but with the torso and legs over the mother’s shoulders. This is repeated in the case of multiple gestation.

EINC in Meconium-Stained Vigorous Infants

The EINC protocol consists of a core sequence of interventions at birth that is applicable to more than 95% of babies who are vigorous at birth. A “vigorous” newborn is defined as one with

spontaneous respirations, and heart rate >100/ min and reasonable muscle tone in the first 15 sec after birth. There is evidence that routine intubation and tracheal suctioning of vigorous infants carries no benefit. There is also evidence that routine suctioning of the mouth and nose of these vigorous infants is not beneficial. Hence, meconium-stained but vigorous infants must receive the EINC protocol similar to non-meconium stained newborns with no unnecessary suctioning applied to these already breathing newborns. Prone positioning during skin-to-skin contact can also facilitate drainage of secretions.

Other special situations where EINC is implemented successfully with policy changes, innovative strategies, staff realignment and modifications of delivery room or operating room choreography include: EINC in vigorous, tachypneic infants, EINC in preterms and Low- Birth Weight (LBW) Infants, EINC in a single- health care worker setting and EINC in tertiary training institutions.

There will always be difficult circumstances and challenging scenarios when performing the EINC protocol. But when health staff experience the benefits of the program, enthusiasm is generated to create strategies to overcome these “presumed” difficult situations and break out from “comfort zones” to create positive change.

F. Infection Control Practices

by Dr. Fay de Ocampo

The unrelenting burdens of maternal and newborn sepsis underscore the urgent need for cost-effective infection-control measures in our crowded health facilities. Classically, infection control practices are perceived to be handwashing campaigns, periodic cleanups and closures after outbreaks and routine antibiotic use. The EINC Scale-up project focuses not only on practices during labor and delivery but prevention of infection as well. Time motion studies, outbreak investigations and weekly meetings in the 11 hospital scale up sites provided rich venues for identifying weak links in the chain, possible sources of infection in the physical environment and helped personnel devise strategies to prevent infection.

Hand Hygiene Campaigns

EINC workshops include exercises on appropriate handwashing and the WHO My 5 Moments of Hand Hygiene campaign on not just how to but

when to handwash. Exercises using Glo Germ™, a fluorescing hand gel served to emphasize the need to observe proper handwashing technique. Posters were made more visible in key areas of the hospitals. Handwashing as a crucial lifesaving measure was introduced early in Objective Struc- ture Clinical Examination (OSCE) of the graduat- ing medical students of the University of the Philippines rather than late in Surgical rotations as medical interns.

Enabling the Policy Environment: Elimination of Routine Antibiotics, Routine NICU Admissions

Implementation of EINC practices made hospital personnel realize that their “preventive practices” were more bent on assuaging their own fears for potential complications rather than a response to the patients’ real needs. Cutting down NICU admissions translated to significantly less congestion and sepsis. Previous policies mandating “nursery” admission of even asymptomatic newborns just because they were born via cesarean section, low birth weight, or with risk factors needing antibiotics were revised. Policies mandating routine laboratory tests (CBCs and blood cultures) and set antibiotics courses are cur- rently still being revised as comfort zones of clinicians are expanding.

Performing the package of EINC core steps has led to more vigorous new- borns, better breastfeeding initiation and less “jittery” health workers; as such, more rational admission to NICUs and antibiotic use.

Enabling the Policy Environment: Elimination of Routine Antibiotics, Routine NICU Admissions Implementation of EINC practices made

Initiation of Exclusive Breastfeeding at Birth

Together with more colostrum ingestion (and we postulate a “repopulation” of the environ- ment with less virulent bacteria), sepsis rates have dropped in the hospitals that have achieved more perfect implementation of the EINC sequence. We look forward to the day when all “nurseries” are no longer and NICUs are closed to essentially well new- borns; babies born by cesarean or with supposed risk factors are directly roomed-in; routine sepsis work-ups are abolished and antibiotics started only when indicated; small but stable newborns stay in Kangaroo Mother Care wards and truly Mother Baby Friendly environments.

That day will come when no mother is turned away from a health facility because there is a sepsis outbreak in

the “nursery”. The future is bright that scenario is happily looming.

. .


Enabling the Policy Environment: Elimination of Routine Antibiotics, Routine NICU Admissions Implementation of EINC practices made

G. Expanding the EINC Campaign Beyond The Hospital’s Borders: Service Delivery Networks

by Dr. Ma. Lourdes Imperial

The EINC Scale-up project succeeded in laying down the foundation of the program in the 11 hospital scale-up sites. The logical progression is to extend the program’s reach by engaging outlying centers in the practice of safe and quality care for mothers and their newborns, and to sustain the program by utilizing tools to monitor outcomes rel - evant to EINC implementation.

Facilities that provide maternal and newborn care within the same vicinity have seen the wis- dom of joining forces to achieve the same goals. It is a fact that the MMR is higher in institutions because the mothers come in already in critical condition from complications of difficult labor. Several scale-up sites sought to counter this by creating linkages to facilitate the transfer of high-risk mothers in need of tertiary care. Out- comes were monitored using instruments such as maternal surveys, and meticulous follow-up post-discharge to determine the effectivity of the EINC practices.

G. Expanding the EINC Campaign Beyond The Hospital’s Borders: Service Delivery Networks by Dr. Ma. Lourdes

By and large, the EINC project has benefitted from both government and private sector-led initiatives to increase awareness of the pro - gram in the catchment areas of our Hospital Sites. We present several models of building service delivery networks.

Partnering with DOH-Center of Health

Development (CHD) VIII – Eastern Visayas, the Eastern Visayas Regional Medical Center (EVRMC) has evolved into the hub for Region 8 (Leyte and Samar) as an EINC Center of Excellence, a BEmONC and also soon-to-be a Kangaroo Mother Care (KMC) training center for the Visayas. The Cotabato Regional and Medical Center (CRMC) has received support from their DOH-CHD XII – SOCCSKSARGEN to serve not only the mothers of Region 12 but also from contiguous ARMM provinces. Of the non- Project sites, DOH-CHD IV-A (CALABARZON) and DOH-CHD XI - Davao Region have initiated trailblazing EINC Workshop series under the MNCHN policy directives and are already reaping the benefits of safe and quality care for mothers and newborns that is not only doable but also cost-cutting.

The Tondo Medical Center and San Lorenzo

Ruiz Women’s Hospital have been spearheading two-way referral efforts for Manila and the CAMANAVA area. Both centers have conducted outreach workshops already at neighboring facilities. The Dr. Jose N. Rodriguez Memorial Center (DJNRMC) is at this early juncture already training midwives and doctors from adjacent private clinics in Caloocan City and Bulacan.

Local Government Units have willingly joined the imperative. General Santos City Hospital has joined forces with the GenSan City govern- ment, in the person of Mayor Darlene Custodio to save the lives of mothers and their newborns

not only in General Santos City but also in Sarangani province. Mayor Guiani of Cotabato City signed a city ordinance to bring EINC to the barangays of his city. Linkages with

Quezon City Councilor Dr. Dorothy Delarmente spawned a workshop series for the Quezon

City Health Department under the leadership of QC Health Officer, Dr. Antoinette Inumer- able. This more extensive system that is

presently being formalized is the QC Service

Delivery Network that seeks to establish linkages between public and private health institutions to provide a continuum of care for mothers and newborns.

and Pilipino. The program can be browsed as a casual or as a Continuing Medical Education user. In the long run we want to design it so the CME mode can be used for credits for accreditation or certification. The features of the SIM include:

instructions on how to use the interactive resources, 10 chapters which include pretests, lectures and post tests and a transcript which can be printed for review, a glossary of terms in English and Filipino, the ENC pocket guide which can be printed, and references.” Dr. Castillo then demonstrated the different functionalities of the SIM.

Mentoring health workers in these expansive areas is allowing EINC inroads into region’s health care system to ensure a more widespread coverage of their mothers and babies to reduce mortality and improve outcomes. It is our hope that robust service delivery networks will eventually bring together all sectors to ensure that no mother and baby will fall through the cracks and be deprived of safe and quality care at the time they need it most, and that through this, more maternal and newborn lives will be saved.

H. The EINC Self-Instructional Module (SIM)

by Dr. Mariella Castillo, WHO

“There is a need to disseminate EINC training to as many health workers fast as possible and even to patients. As part of this joint program we are working with academe to incorporate it in curriculum and board exams. We have developed training materials that you can show even off-site, by computer or distance learning. We are finalizing the SIM. This is designed to have a pretest, and a video chapter which is essentially what has been presented by the Forum presenters. After this, the learner will have to answer a post test. This is in English

not only in General Santos City but also in Sarangani province. Mayor Guiani of Cotabato City

IX. Forum Discussions

Moderated by Dr. Anthony Calibo, NCDPC

Dr. Mildred Pareja, Chair of the Board of Medicine, Philippine Regulatory Commission, asked the first question, but began by congratulating everyone for the work completed. Her first question: was there a relationship between the length of hospital stay of the newborn with the rate of infection? Second, related to the surgery or CS delivery and the attempt to dry the baby within the operative field by asking an intern alone to scrub and crowd out the operative field. Dr. Pareja

said – it seems that drying can be done outside of the operative field since it will not distract the surgeon from the task. She emphasized that “we are concerned not only with the newborn but also the mother.” She added that in her practice she often asked the nurses to prepare a thick receiving blanket to keep the newborns warm and transfer them to a separate area.

Dr. Silvestre said that we are still in the process of data collation and once completed, the data on hospital stays will need further analysis. In our hospital experience and even in settings where a solitary health worker attends to both mothers and babies, all four core steps from drying to breastfeeding initiation can performed by the solitary delivery attendant.

Dr. Pareja commented that in government hospitals there are so many deliveries and so many beds that a fast discharge becomes important. Can we safely discharge a baby only after 24 hours? She recounted that then they decided to be bold, and discharged after 12 hours. This is an area that should be looked into.

Dr. Cynthia Tan responded to the issues raised by Dr. Pareja on applying EINC in CS. She said that it has to be done in the operative field since drying has to be done before the cord is cut. We put the newborn in the hollow between the legs of the mothers. We do not need a pediatric intern or pediatric resident to scrub in. The entire team participates in the drying of the baby, even the surgeon. After the cord is cut, the baby is transferred to the head part or the area of the anesthesiologist.

Dr. Ma. Luisa Manlapaz of St. Luke’s Medical

Center-Quezon City commented on the drying

of the newborn during CS. She admitted that in adopting it in St Luke’s, there have been a lot of kinks to be ironed out. This is handled by the St.

Luke’s EINC Committee. In cesarean section, we dry the baby in the operative field but continue drying the baby in the radiant warmer. When the newborn is very dry, they are transferred to the mothers’ breast. She commented that there are instances where the skin of the mother is cold and has not provided warmth to the newborn. This was a result of anesthesia administered. She also observed that without the routine monitoring of the mothers temperature and the newborn, the newborn can become hypothermic.

Dr. Brion said that we emphasize in EINC that the first step is the immediate and thorough drying of the newborn for 30 seconds. If there is a necessity for further drying in the radiant warmer, this can happen after the first step has been done. It is further suggested that the wet towel is changed by a dry towel. She further emphasized the need for monitoring of the mother and baby and that the room temperature should be between 25 to 28C. This is one of the challenges we need to address.

Dr. Edward Tandingan of Helen Keller Intl congratulated the Team in their EINC work. He made a clarification on the use of oxytocin. Dr. Tan responded that administration of oxytocin should be done within 1 minute of the delivery of the baby.

He also commented that it is heartening to know that DOH’s intent is for EINC to reach the most peripheral of areas. Since most of the deliveries are not in the hospitals and will need to mobilize midwives in the work, how will EINC reach the midwives. Dr. Tan said that midwives are always included in the orientation workshops. The Association of Philippine Schools of Midwifery (APSOM) is part of the program for curriculum change. Clinical instructors of APSOM have been trained in EINC.

NCDPC Director Honorata Catibog clarified that EINC is being done in private midwifery clinics. Are the midwives allowed to inject oxytocin in the active management of the third stage of labor? Admittedly in the midwifery law, midwifes are not allowed to administer oxytocin. But in the DOH administrative order for MNCHN, within the context of setting up a service delivery network that encourages a team approach, headed by a physician, nurse and midwife – this can be done, as long as midwives are under the supervision of physicians.

On another track, Dr. Pareja emphasized the importance of the education of the mothers and their development of a birthplan in promoting EINC. She shared that in the early years of her practice, her mind was opened by a mother who practiced Lamaze. EINC is very basic – and can be seen as going back to basics – without any sophistication. “I find it very important for the mothers to be educated and prepared for birth. Is this part of EINC ? <audience answered yes> – this is very important and should be included and emphasized.

Is there a mechanism for proficiency certification of midwives so they can do AMTSL? Dr. Tan commented that there are training programs for capacity enhancement of midwives. Midwives are allowed to provide emergency drugs if they undergo training. There is the POGS training which are conducted in most of the provincial hospitals all over the country. The POGS MDG program is being held in cooperation with the IMAP and the PSNbM.

Ms. Patricia Gomez of the Integrated Midwives’ Association of the Philippines said they have always emphasized to their midwives that the provision of life saving drugs should be done during emergency especially if their facility is 2 to 3 hours from hospitals. Ms. Gomez requested

the Department of Health to have midwives trained in Unang Yakap – the DR midwives. She reiterated that there is no special item for hospital midwives even if they are doing work in hospitals. IMAP plans a training of trainors on EINC in Luzon, Visayas and Mindanao so it can be cascaded to all midwives. Dr. Catibog explained that the nonexistence of a plantilla item for midwives reflects the traditional view that midwives were best employed in rural health units but with the promotion of facility based deliveries under the MNCHN strategy, changes are expected to take place. A rationalization plan has been prepared which includes plantilla items for midwives.

X. Summary of the Forum

by Dr. Ruben Flores, Director, Dr. Jose Fabella Memorial Hospital

Essential Intrapartum and Newborn Care (EINC) aims to reduce harmful and old practices being done to birthing mothers and their newborns in Philippine health facilities. Policy guidelines have been issued by the Department of Health which encourage the full adoption of these evidence-based practices: Administrative Order 2008-0029 (MNCHN Strategy, BEmONC/CEmONC), Administrative Order 2009-0025 for Essential Newborn Care and Administrative Order 2007- 0026 on the revitalization of the Mother Baby Friendly Hospital.

If you noticed in the presentation of Dr. Jose Fabella Memorial and other hospitals, data was presented on what was done before and is now being done. All participating hospitals noted that there is the need to embrace the new protocol since it is evidence-based and supported by DOH policies. Notably, there were variable implementation and a lot of innovation as each hospital sought to

adopt the protocols. But in the future, as the program rolls out, it is expected that there will be a unified and standardized implementation of the program since the protocol is time- bound and there is a reason for each step to be done in a particular sequence.

The program has been implemented in 11 hospitals, DOH retained NCR, DOH-retained Regional, LGU hospitals and an academic/state university hospital. Now, the challenge is how to sustain the practice and institutionalize the program. The pilot showed that there are more difficulties in implementing the program in big hospitals when compared to the results in the smaller hospitals. The bigger the hospital, the bigger the challenges.

In summary, here are some lessons learned in the pilot implementation of EINC, 2010 to


Lessons Learned

  • n Unlearning “old” and “harmful” practices

that contribute to maternal and neonatal morbidity and mortality.

  • n Cross-cutting implementation

  • n Technology transfer needed to “update”

new evidence for health staff on the new

evidence-based EINC

  • n Value of birth plan and partograph which

is actually a standard practice in all hospitals

providing maternity care

  • n Antenatal steroids and protocol for

potential preterm births where evidence shows that mothers with preterm births, who were administered antenatal steroid, had a better change of their infants surviving

  • n IM Oxytocin and active management of

3rd stage of labor (AMTSL) after the baby is out

  • n True “non-separation” of the newborn

from his/her mother possible >90%

  • n Communication and cooperation among

involved stakeholders and specialists needed

  • n Active participation of all hospital staff. All

need to be oriented.

  • n Medical Center Chief’s/Chief of Hospital’s/

Medical Director’s leadership needed to make things happen and provide the necessary logistical support and policy.

The Way Forward

  • n For recipient hospitals of capacity building

on EINC scaling-up, continued and pro-active implementation, to serve as role models for other government and private hospitals in functional service delivery networks.

  • n The 11 hospitals who participated in the

scale up are role models for other government and private hospitals in functional service delivery networks. In Jose Fabella, numerous requests have been received to learn about EINC.

  • n For remaining hospitals, conduct internal

assessments of existing practices and review needed changes even without the prompting

of DOH.

  • n CHD Regional Offices to work closely with

DOH-retained hospitals, LGU counterparts and

private sector for implementation

  • n EINC “Advocacy Partners” and various

partner institutions are needed to support health human resource requirements for

capacity building and advocacy.


  • n Need to localize the MNCHN Strategy

as an overarching strategy for improving

maternal and newborn health outcomes all over the country

  • n Full scale implementation of EINC

through CHDs regional scaling up activities in cooperation with EINC Advocacy Partners

because it is only a few years before 2015, the reckoning year for achievement of the MDG


  • n Strengthen sustainability mechanisms

  • n Monitoring and evaluation

  • n Operational research

Every single mother and newborn in our country deserves the highest standard of care. Every mother and newborn in our country deserves EINC.

Mabuhay ang EINC! Mabuhay ang Unang Yakap!

XI. Moving Forward & Next Steps

by Dr. Teodoro Herbosa, Undersecretary, Department of Health

Who would think that this Unang Yakap project piloted in hospitals would be classified as a critical public health service?

I am particularly interested in today’s forum because as the DOH Area Operations Cluster Head for NCR and Southern Luzon, I will be held accountable for achieving Kalusugan Pangkalahatan in my cluster. And my cluster happens to be where the largest number of maternal mortalities are! And you know that where mothers die, babies are more likely to die, too. Not only that, but the most number of DOH-retained and specialty hospitals are in my cluster as well. So I am very thankful to the Team EINC with the support of WHO under the DOH-AUSAID UN Joint Programme on Reducing Maternal and Neonatal Mortality as well as NCDPC and NCHP for developing this very critical support and technical assistance that will help us achieve our MDG related goals.

I see the potential of Unang Yakap for rapid roll

out because it can show quick results, can be

scaled up using non-traditional methods, and is a logical entry point for patient safety and quality improvement initiatives. At the same time, every health worker has a role to play to achieve population effect in the shortest

possible time.

It is the rapid adoption of

Unang Yakap that matches our national need to solve the nagging problem of maternal and newborn deaths. So it helps that the practice of EINC…

1. Can show quick results

We can start off with results at the facility

level then roll it out to district service delivery

networks then to the regional level. Quick

results are improvements in processes first, then followed by surrogate clinical outcomes then hopefully in reductions in the mortality and morbidity outcomes. But in the meantime, patient satisfaction also goes up, which I am sure all hospitals would like to see. The same goes for hospital efficiency.

2. Can be rapidly scaled up

The 1-day methodology and the computer- based learning veer away from the slow traditional, expensive methods. I would like to emphasize the utmost importance of scheduled mentoring and follow–up assessments if indeed health workers’ behaviour changes are sustained. DOH hospitals can be the leader in engaging LGU counterparts and the private sector to train as many people as soon as possible.

3. Is an entry point for patient safety and quality improvement initiatives

The way I see it, the Unang Yakap process is

essentially a quality improvement initiative. And even though it was applied in a hospital setting, it is in all practical sense low- technology, cost-effective, and high-impact and thus can be naturally and seamlessly adopted in the public health setting. In fact the Team experience showed that it was more easily and fully embraced in the smaller facilities than in the large medical centers.

Unang Yakap has also become a model for a health systems approach to effectively deliver a key intervention in the Maternal Newborn and Child Health & Nutrition (MNCHN) framework. Some of the system elements in support of the sustainability of Unang Yakap initiatives are revisions in the Maternal Care and Newborn Care package of PhilHealth, the beginnings of Service Delivery Networks borne out of EINC trainings for referring centers by some of the 11 hospitals, and curricular reforms for our future health workers. Unang Yakap brings together LGU managers, public health and primary care providers side by side with hospital managers and specialists to work towards achieving the MDGs. The possibilities for collaboration are endless.

of the poor. When we deploy these CHTs we should also be prepared to supply the demand.

It was proven that in 11 hospitals where collectively more than 70,000 women give birth every year, safe and quality care can be the norm. Let’s take advantage of the momentum generated by Unang Yakap. Let this spread nationwide.

Yakapin ang EINC sa lahat ng ospital at health facilities!

In Kalusugan Pangkalahatan, we are enhancing hospitals and health facilities with

adequate supply of public health commodities

and drugs. We are deploying


Health Teams (CHTs) to increase the demand and access for better quality inpatient and outpatient care – especially for the poorest

Part Three. Participating Hospitals & Team EINC XII.I Cotabato Regional and Medical Center (CRMC) Cotabato Regional

Part Three. Participating Hospitals & Team EINC

XII.I Cotabato Regional and Medical Center (CRMC)

Cotabato Regional and Medical Center (CRMC) is a Level IV Tertiary, Teaching and Training hospital operating under the supervision of the Department of Health. Initially a 12-bed capacity hospital in 1916, the hospital was upgraded to hold an authorized bed capacity of 400. Geographically, CRMC is situated in Central Mindanao located in Cotabato City. It caters to two (2) administrative regions namely:


  • n Autonomous Region of Muslim Mindanao (ARMM) : Maguindanao, Shariff Kabunsuan, part of Lanao del Sur (Malabang and Marawi City) and part of Zamboanga del Sur (Pagadian).

The Cotabato Regional and Medical Center provides accredited Post-Graduate training pro- grams in Surgery, Internal Medicine, Obstetrics and Gynecology and Pediatrics by the Depart- ment of Health and their respective specialty societies.

It also serves as a training facility for seven affiliated nursing schools:

  • n Notre Dame University - College of Health Services

  • n Dr. P. Ocampo Colleges, Inc.

  • n Cotabato Medical Foundation Colleges, Inc.

  • n Notre Dame of Midsayap

  • n Notre Dame of Kidapawan

  • n North Valley College Foundation, Inc.

  • n San Pedro College

and three Midwifery Schools:

  • n Notre Dame Hospital School of Midwifery

  • n Dr. P. Ocampo Colleges, Inc.

  • n Southern Christian College

CRMC is the leading institution in the delivery of maternal and newborn care services in the province. In the 2010 census, CRMC had a total of 6,246 obstetric admissions and 4,214 live births, 31.7% of which were admitted at the Neonatal Intensive Care Unit (NICU). At present, the hospital has been identified as a training hospital for Basic Emergency Obstetrics and Newborn Care (BEmONC) and the collaborating institution of the Essential Intrapartum and Newborn Care (EINC).

Hospital Director:

Dr. Helen P. Yambao

CRMC EINC Working Group:


Dr. Ma. Theresa Tenorio Dr. Cosmina Macawadib – Obstetric EINC Resident


Dr. Ashmere Abbas – Pediatric EINC Resident

Dr. Chenery Lim


Dr. M. Hollis – Head, Anesthesia


Mrs. Elvira Macayran – Site Coordinator Renette S. Gonzales – OPD Nurse Diomarise P. Macuha – Pediatrics Nurse Editha A. Lansangan - Pharmacy Sofia D. Alfonso – Pharmacy Leonita Lu – Pediatrics Nurse Junar P. Jakosalem – OB-Gyne nurse Vernon Uy – OR Nurse



Dr. Tetchie Cadiz-Brion Dr. Jessamine Sareno

Project Staff:

Dr. Chenery Lim Dr. Sweet Almira T. Ali-Amil Dr. Alfred Songcayauon

XII.II Dr. Jose N. Rodriguez Memorial Hospital (DJNRMH) The Jose N. Rodriguez Memorial Hospital (DJNRMH) ,


Dr. Jose N. Rodriguez Memorial Hospital


The Jose N. Rodriguez Memorial Hospital (DJNRMH), formerly known as Central Luzon Sanitarium, was established in 1940, to accommodate patients suffering from Hansen’s Disease in the entire Luzon region in the Philippines. It is currently situated within the district of Tala, in Caloocan City, Metro Manila, and occupies 130 hectares of land area, from the original 808 hectares. Reduction of land area is to accommodate previous homeless treated patients eventually settled and established their own community, called Tala.

In 1970, the hospital began treating general medical cases (non-Hansen disease patients) when there was a high success rate of treatment of the first Hansen patients from research and the advancement of procedures done within the current medical practice. Due to the significant drop of Hansen patients the hospital then considered admission of general cases. The hospital currently serves as the principal referral hospital for leprosy patients and the premier train- ing and research center for leprosy care and management in the Philippines. It also serves the public health needs of community members of Tala and nearby areas.

Today, DJNRMH is mandated to provide tertiary general care services with the approval of the Implementing Rules and Regulations of RA 9420 : an Act converting the 200 beds of Dr. Jose N. Rodriguez Memorial Hospital for Tertiary General Health Care, appropriating funds therefore and for other purposes.

The hospital has 7 beds in the Mother-Baby Friendly ward which admits obstetric cases, both NSD and CS. The hospital also trains nurses from different nursing schools in Manila. It has a newly renovated OB ward that has 7 additional beds, effectively doubling the bed capacity for mothers.

The hospital is also a training hospital for the following nursing schools: Far Eastern University Hospital (Morayta, Manila), La Consolacion College (Caloocan), Norzagaray College, University of Pangasinan, Arellano University, and Our Lady of Lourdes Hospital (Caloocan).

Led by their Hospital Director, Dr. Edgardo S.A. Javillonar the hospital environment was en- abled for EINC practices starting March 2011. Their graduation ceremony in September 2011 coincided with the opening of their EINC Ward.

DJNRMH Hospital Director:

Dr. Edgardo S.A. Javillonar

DJNRMH EINC Working Group:

Dr. Edgardo Javillonar (Medical Director)

Dr. Fortunato Boto, Jr. (OB Site Coordinator)

Dr. Fatima Dasalla (Pediatrics Site Coordinator)

Dr. Maribel Agustin (Pediatrics)

Dr. Amelia Calderon (Anesthesia)

Ms. Yolanda Sales (DR nurse)

Ms. Emma Abarejo (DR nurse)

Mr. Kemmerson Catha (OR nurse)

Ms. Amalia Villar (ER nurse)

Ms. Angelita Villavert (Budget Officer)



Dr. Ma. Lourdes S. Imperial

Project Staff:

Dr. Gemma Gregorio

Dr. Ma. Blesilla Bertos

XII.III Dr. Jose Fabella Memorial Hospital The Hospital was founded in 1920. It is designated as

XII.III Dr. Jose Fabella Memorial Hospital

The Hospital was founded in 1920. It is designated as the Na - tional Maternity Hospital by the DOH as per AO No. 11 s. 1990. It operates the only School of Midwifery of the DOH since 1922. Its present site is the administration building of the Old Bilibid Prison Compound. The institution is internationally recognized for its maternal & child health services & family planning by the WHO, UNICEF, USAID, UNFPA Family Health International, Georgetown University & University of Oxford. It has been a WHO Collaborating center for Repro - ductive Health Research with Departments of Obstetrics and Gynecology, Neonatology and Pediatrics.


  • n To upgrade JFMH into a 3rd level referral

hospital in the field of reproductive health within 5 years.

  • n To enhance research activities in collaboration with local & international organizations.

Hospital Category/Bed Capacity

Service Capability:

Level 4/Tertiary Care (Teaching & Training)

Nature of Ownership:

National-DOH Retained Hospital

Bed Capacity:

Authorized : 700 beds Implementing : 521 beds

Bed Distribution:







Surgical Pediatrics




T o t a l


Hospital Director:

Dr. Ruben C. Flores

DJFMH EINC Working Group:


Dr. Maria Carolina Mirano Dr. Christine Tumale Dr. Mary Ann Ilao


Dr. Mary Rose Panlilio-Asuncion Dr. Roberto Montana Dr. Ma. Cynthia Fernandez - Tan


Ms. Edna Solis Ms. Jocelyne Timola Ma. Nancy C. Guia Ms. Teresa Rallos


Dr. Generosa Aguas


Dr. Cynthia Fernandez - Tan Dr. Ana Melissa Francesca Tatad - To Dr. Fay de Ocampo

Project Staff:

Dr. Trinia Asuncion Dr. Girlie Larroder

XII.IV EAST AVENUE MEDICAL CENTER (EAMC) The East Avenue Medical Center was organized by virtue of


The East Avenue Medical Center was organized by virtue of EO #48s. 1986 of President Corazon C. Aquino. It originated as the GSIS Hospital, a 500 bed capacity institution catering to the members of GSIS and their dependents, before it was transferred to the government. After its dissolution, it was renamed Ospital ng Bagong Lipunan, established on January 8, 1978 by virtue of Presidential Decree No. 1411. After the 1986 EDSA Revolution, the East Avenue Medical Center was organized by virtue of Executive Order 48s of President Corazon C. Aquino. The bed capacity was reduced to 350 with the intention of accommodating service patients and training its staff in different fields of specialization. Since then, EAMC has been moving progressively with the aim of living up to its standard as a premier education and training center as well as a service hospital under the Department of Health. Constructions and repairs are on-going hand in hand with the efforts to give high quality standard of patient care to the optimum number of populace irrespective of social, educational, economic and religious creed. “There is always room for improvement” is the or- ganization’s guiding principle, thus, despite some problems brought about by the pressures of development and change, the management is doing its very best to cope and move progres- sively with the times.

The hospital has a bed capacity for the OB-Gyne patients of 117: 60 in the North ward, 12 in the West ward and 35 in the East ward. A Birthing Center will be opening soon with a bed capacity of 40 that will cater to normal deliveries.

The hospital is a teaching institution. For medical clerkship, the following medical schools send their students for training: Cagayan State University, St. Luke’s Medical Center, San Beda Col- lege, Ateneo University, FEU and UERM. Nursing schools also send their students for a DR-LR rotation: Universal College of Nursing, St. Paul University Manila, Perpetual Help College of Laguna, Perpetual Help College of Manila, Centro Escolar University, UERM, St. Luke’s (Trinity Univ. of Asia), St. Joseph College, Our Lady Of Fatima University, UST, FEU UDMC-SACI, Lanting, NCBA and Capitol Medical Center.

Hospital Director:

Dr. Rolando L. Cortez

EAMC EINC Working Group:


Dr. Patricia Malay-Kho OB (Site Coordinator)

Dr. Gina I. Malaluan (Resident)


Dr. Grace Verzosa Dr. Hilario John R. Mangoba Dr. Charise Malong Dr. Bernadette Corpuz (Resident)

Nursing Service:

Flor P. Burgos (Nurse Supervisor, DR) Editha C. Gellera (Nurse Supervisor, NICU) Zelda A. Valdez (Nurse Supervisor, 3-I) Myrna A. Claveria (Nurse Supervisor 3-W) Arsenia S. Barrios (NIII)

Nursing Service:

Flor P. Burgos (Nurse Supervisor, DR) Editha C. Gellera (Nurse Supervisor, NICU) Zelda A. Valdez (Nurse Supervisor, 3-I)

Myrna A. Claveria (Nurse Supervisor 3-W) Arsenia S. Barrios (NIII) Rosario N. Bernal (Nurse Supervisor, OPD)


Dr. Ma. Lourdes S. Imperial

Dr. Teresita Cadiz-Brion

Project Staff:

Dr. Maria Nerizza Trinidad-Flores

Dr. Maria Blesilla Bertos

XII.V Eastern Visayas Regional Medical Center (EVRMC) The Eastern Visayas Regional Medical Center , then known

XII.V Eastern Visayas Regional Medical Center (EVRMC)

The Eastern Visayas Regional Medical Center, then known as the Leyte Provincial Hospital, opened to the public on July 16, 1916 at

Jones Street with a bed capacity of 14. The hospital was relocated (to its present site) and a new building was constructed in 1925. In 1936, the hospital was further expanded to 40 beds and the new building was

inaugurated by President Manuel L. Quezon.

In 1952, the bed capacity of the hospital was further increased to100. On July 6, 1970, the hos- pital expanded its role in the region by formally opening the Leyte Provincial Hospital School of Nursing, the 7th School of Nursing under the Department of Health and the only school of Nursing in Leyte and Samar. In 1972, the bed capacity was increased from 100 to 250 and its name changed to Speaker Daniel Z. Romualdez Memorial Hospital.

The Department of Health in 1973 by virtue of R.A. 6527, designated the hospital as a regional teaching hospital. It is also the end referral hospital of all government hospitals in the Region. It merged the three hospitals (the Tacloban City Hospital, the Leyte Provincial Hospital and the Speaker Daniel Z. Romualdez Memorial Hospital). The Regional Laboratory was also integrated with the SDZR Memorial Hospital.

In 1984, the Residency Training Law resulted in the accreditation of the Clinical Departments. At present, the following Residency Training Programs are all accredited by their respective Specialty Societies: Internal Medicine (Philippine College of Physicians), General Surgery (Phil- ippine College of Surgeons), Pediatrics (Philippine Pediatric Society), Obstetrics and Gynecol- ogy (Philippine Obstetrics & Gynecologic Society), Pathology (Philippine Society of Pathology), Anesthesia (Philippine Society of Anesthesia) and Family & Community Medicine (Philippine Academy of Family Physicians). The Residency Program of the Department of Radiology was suspended since 2008 because the hospital has no CT Scan yet while the Residency Programs of the Departments of Orthopedics, Psychiatry, Ophthalmology and ENT are currently prepar- ing themselves for accreditation.

On March 24, 1992 by virtue of Republic Act No. 7879, TCMC was renamed as the Eastern Visayas Regional Medical Center (EVRMC).

The EVRMC today is a modern, tertiary level four (4) teaching and training hospital strategically located along Magsaysay Boulevard, Tacloban City. Its 15 buildings occupy a total land area of 25, 639.36 square meters on land owned by the Provincial Government of Leyte. Its present location is conducive for prompt medical assistance to the people of Region VIII since it is ac- cessible and strategically located midway between Samar and Leyte.

Hospital Director:

Dr. Aileen T. Riel-Espina (OIC)

EVRMC EINC Working Group:


Dr. Aileen T. Riel-Espina (OIC) Dr. Loreta Yu-Rama (Training Officer)


Dr. Alberto Agosto (Chairman) Dr. Jesusias Magdayao (Consultant) Dr. Ivy Lozada (Consultant) Anesthesia Residents





Dr. Perla T. Romo (OB Chair)

Dr. Susana S. Merida (Consultant, Site Coordinator) OB Site Residents

Dr. Cynthia Tan Dr. Ina Pelaez-Crisologo Dr. Francesca Tatad-To Dr. Jessamine Mae C. Sareno


Dr. Rhodora V. Angulo (Chairman) Dr. Nelita P. Salinas (Consultant, Pediatrics Site Coordinator) Dr. Ma. Gemma Ramos (Consultant) Dr. Audrey Katherina Santo (Consultant) Dr. Ligaya Nicolasora (Consultant) Pediatric Residents


Ms. Dolores Y. Casio (Nursing Site Coordinator)

Ms. Teresita Berenguer (Chief Nurse) Ms. Milagros Corillo (OB Nurse Supervisor) Ms. Judita B. Darang (DR Supervisor) Ms. Violeta D. Lozada (OR Supervisor)

Project Staff:

Dr. Ma. Rosita O. Adolfo Dr. Marie Ann C. Corsino

School Affiliates:

UP-Integrated School of Health Sciences Holy Infant College of Nursing and Midwifery St. Scholastica College of Nursing Remedios Trinidad Romualdez Medical Foundation College of Medicine and College of Nursing San Lorenzo Ruiz College of Nursing, Ormoc City Our Lady of Sta. Lourdes Foundation Inc. College of Nursing

XII.VI General Santos City Hospital (GSCH) General Santos City Hospita l is an LGU-devolved hospital since

XII.VI General Santos City Hospital (GSCH)

General Santos City Hospita l is an LGU-devolved hospital since 1991 but has been in operation since 1975. A Level 2 hospital with tertiary functions, GSCH has a 100-bed authorized capacity but has 261 implementing beds. It caters to approximately 261 in-patients and 100 outpatients daily. Newborn deliveries comprise 22% of the total admissions in 2010.

GSCH is the only government hospital within “SOCCSKSARGEN” area with better facilities, thus catering to patients from other neighboring municipalities such as Sarangani Prov - ince, South Cotabato, Sultan Kudarat and Davao del Sur. It serves as a training hospital.

GSCH is an LGU-devolved hospital since 1991 but has been in operation since 1975. A Level 2 hospital with tertiary functions, GSCH has a 100-bed authorized capacity but has 261 implementing beds. It caters to approximately 261 in-patients and 100 outpatients daily. Newborn deliveries comprise 22% of the total admissions in 2010.

The Hospital started their EINC practice last March 2011and graduated this month.

Hospital Director:

Dr. Benjamin G. Pagarigan, Jr.

GSCH EINC Working Group:

Site Coordinators:

Dr. Charlie Alcaide Dr. Consuelo Lu Tessie Tarrobago, RN

Team Working Group:

Grace Solamo, RN Edna Almajose, RN Lorelie Sabado, RN Ann Canamay, RN Gregoria Siodora, RN

Lalaine Talimongan, RN Margie Juinio, RN Shelaine Copreros, RN Doris Tingco, RN Jeffrey Causing, RN Nenita Alemania RN



Dr. Teresita Cadiz- Brion

Dr. Jessamine Mae Sareno

Project Staff:

Dr. Ma. Christina B. Domingo

Dr. Sheena Emily S. Elago

XII.VII Jose R. Reyes Memorial Medical Center (JRRMMC) JRRMMC started in 1945 as a 100-bed emergency

XII.VII Jose R. Reyes Memorial Medical Center (JRRMMC)

JRRMMC started in 1945 as a 100-bed emergency hospital for civil- ian casualties under the Philippine Civilian Affairs Unit or PCAU-5, and gradually transformed into a 450-bed teaching, training medical center. On August 1, 1945, it was renamed North General Hospital (NGH) and placed under the control and supervision of the Bureau of Health. In 1947, it became a training hospital under the Department of Health. By virtue of R.A. 4264 passed on June 1965, NGH was renamed Dr. Jose R. Reyes Memorial Hospital in honor of Dr. Jose R. Reyes, its Chief of Hospital from March 16, 1948 to January 24, 1964. On December 3, 1982, Executive Order No. 851, renamed it the Jose R. Reyes Memorial Medical Center.

On January 31, 1987, E.O. 119 which provided the reorganization of the Department of Health, included the integration of the National Cancer Control Center (as Department of Radiotherapy) and Dermatology Research Center. Again, on May 24, 1999, by virtue of E.O. 102, two services from DOH, Medical Infirmary (MEDI) and Dental Health Services were integrated with JRRMMC.

The institution is continuously pursuing its vision to be the Center of Excellence for Health where patients are assured of effective, efficient, accessible state of the art services which are and will be provided by highly competent, compassionate, committed staff, and will be the prime teaching/training and research institution for medical and allied professions. Now a tertiary training and teaching hospital, JRRMMC with an authorized 450 bed capacity and a separate building for ambulatory patients, has a mission to provide quality care through delivery of general health services, implementation of disease prevention and health promotion programs, efficient utilization of resources, continuous strengthening of human resources development programs for staff, affiliates and trainees, regular upgrading of facilities, effective institutionalization of responsive policies and standards and relevant research endeavors.

Hospital Director:

Dr. Ma. Alicia M. Lim

List of Affiliating School for Nurses:

Concordia College, Manila Chang Kai Shek College, Manila De Ocampo Memorial College, Manila Mt. Carmel University, Bulacan Our Lady Of Fatima University, Manila

Olivarez College, Las Pinas Pamantasan ng Lunsod ng Maynila, Manila Perpetual Help College, Manila

Philippine Rehabilation Ints. Foundation, Quezon

City Arellano University, Manila La Consolacion College, Manila St. Jude College, Manila Centro Escolar University, Manila

Affiliating School For Medical Clerks

Far Eastern University Our Lady Of Fatima University Virgen Milagrosa University

Saint Louis University, Derma Only University of Perpertual help – ENT & Optha only

Medical Interns are under APMC

Hospital Affiliates Of Residents:

National Childrens Hospital - NICU Far Eastern University-NRMF Medical Center - OB Metropolitan Medical Center - OB Makati Medical Center - OB

JRMMC EINC Working Group:

Dr. Maela Villaruz - Pedia Site Coordinator

Dr. Lani Coloma - OB Site Coordinator

Summer Affiliates:

Aquinas University, Bicol Ateneo De Naga, Naga City Medical Colleges Of Northern Philippines,Tuguegarao Lyceum of Aparri, Aparri, Cagayan St. Mary’s University, Nueva Viscaya St. Paul University, Tuguegarao University of St. Loius Tuguegarao, Tuguegarao Tabacco College, Bicol Truman State University, Missouri


Ms. Eligia Capito - HEPO Ms. Teresita Clarin, OB Ward/OB Ext

Ms. Jasmin Valerio, OB Ward/OB Ext Ms. Teresita Rubio - (DR/NICU)

Ms. Herminia Queliza, PACU/SICU

Ms. Gliceria Yu, NTO Ms. Presentacion Pacete, OPD-N Ms. Mary Grace Foronda - ICC

Affiliating School for Midwives

Medical Colleges Of Northern Philippines,Tuguegarao


Co-Convener: Dr. Francesca Tatad - To Project Staff: Dr. Renee Tana

XII.VIII University of the Philippines - Philippine General Hospital The University of the Philippines - Philippine

XII.VIII University of the Philippines - Philippine General Hospital

The University of the Philippines - Philippine General Hospital

trains an average of 160 medical students from the UP College of Medicine annually. This same number will usually be accepted as medical interns in their last year at medical school. An additional 80-90 post graduate interns from other medical schools are also accepted from the most qualified of approximately a thousand applicants from all over the country. These medical

interns undergo a rigorous course of clinical rotation in all departments and their respec -

tive sections for one year.

Didactics, ward rounds and preceptorship, emergency room

duties, out-patient clinics, operating theater rotations and departmental and interdepart-

mental conferences are included in the clinical rotation.

PGH exists because, in health, we are our brother’ keepers. With a “TATAK PGH” manner of treating our patients, we ensure that all patients understand their conditions and are able to participate in their own treatments. There are 19 clinical departments each with its own array of general, specialty, subspecialty and cutting edge units, offering excellent facilities. It ensures the delivery of comprehensive care for both healthy and sick Filipinos, especially the poor and marginalized.

The Philippine General Hospital recognizes that research is an integral part of being a University Hospital. Furthermore, the PGH realizes that quality training and service are enhanced by quality research.

The PGH research committee was established in 1995 to address the hospital’s research needs. In the same year, the first PGH Residents’ and Fellows’ Forum was held followed shortly by the first PGH Nurses’ Research Forum. The first issue of the PGH research journal was also published in 1995. In 1996, several research activities were undertaken, the PGH Ethics Committee was formed and a Hospital Research Week was held. A research fund was also set up to fund commissioned researches and grants.

Hospital Director:

Dr. Jose C. Gonzales

PGH EINC Working Group:

Site Coordinators:

Dr. Resti Ma. Bautista

Ms. Gloria Almariego

NICU Fellows:

Dr. Kharen Abat-Senen Dr. Jerome Wangdali Dr. Fay de Ocampo Dr. Bianca Bhani Maglana Dr. Renalyn Ignacio Dr. Janelle Margaux Logronio Dr. Cherie Lou Nazareth

OB Resident:

Dr. Ghea Mata


Ms. Rosemarie Uro



Dr. Donna Capili Dr. Ina Crisologo Dr. Ernie Uichanco Dr. Fay de Ocampo

Project Staff:

Dr. Beverly Lorraine Ho

Dr. Rani Cadiz

XII.IX Quirino Memorial Medical Center (QMMC) Standing in an elevated ridge overlooking the Marikina Valley, this

XII.IX Quirino Memorial Medical Center (QMMC)

Standing in an elevated ridge overlooking the Marikina Valley, this

42,000 sq. meters of edifice, caters not only to the Quezon City resi- dents and immediate community but all the neighboring towns of Marikina, Antipolo, San Mateo, Montalban, Caloocan, Novaliches and even the nearby provinces of Laguna, Bulacan, Cavite and the like.

Formerly known as the Labor Hospital, QMMC was built and organized

for the service of the indigents on August 15, 1953 during the tenure of

the late Pres. Elpidio Quirino. Later, it was named as Quirino Memorial General Hospital on Aug

15, 1964 pursuant to PD 3975 then to Quirino Memorial Medical Center pursuant to EO 119

with a 350-bed capacity from 250 to 350 under RA 8313 in 1997.

QMMC was established in 1951, through the generous donations of civic minded people, Phil- ippines Charity Sweepstakes Office (PCSO) and the Department of Labor (from where its name was originally taken) which operated under the auspices of the Department of Health.

It formally opened its doors to the public on August 15, 1953 as the first government hospital

in Quezon City. A “PEOPLE-ORIENTED INSTITUTION” with the primary goal of reaching out to

the sick and infirm.

The hospital started with EINC in February of 2008 through the efforts of Dr. Bella Vitangcol. Several trainings were conducted to update the staff and train the newest addition to the

QMMC family.

Hospital Director:

Dr. Angeles T. De Leon

EINC Working Group:

Nursing Service:

Ms. Eleanor Mendoza Ms. Virgie Echiverri



Dr. Ireene Cacas


Dr. Anne Claudine R. Zamora (resident)

Dr. Ernesto Uichanco Dr. Ma. Lourdes Imperial


Dr. Bella Vitangcol Dr. Ma. Antonette Co-Del Valle Dr. Sharon Delfin (Chief Resident)

Project Staff:

Dr. Maria Blesilla Bertos Dr. Maria Nerizza Trinindad-Flores

XII.X San Lorenzo Ruiz Women’s Hospital (SLRWH) San Lorenzo Ruiz Women’s Hospital is a 10-bed capacity

XII.X San Lorenzo Ruiz Women’s Hospital (SLRWH)

San Lorenzo Ruiz Women’s Hospital is a 10-bed capacity special First Level Referral hospital catering to the health needs of women and chil- dren. It is accredited by PhilHealth as a secondary hospital.

In 2005, the total number of patients seen in the different departments were 1,418. Of which 1,192 were admitted to the Emergency Room, 164

were in the Outpatient Department and 62 were direct admissions.

The Bed Occupancy Rate

was 117.8%. The total in-patient service days were 4,281 with an average length of stay of 3 days.

Total number of discharges (alive) was 1,400. Referrals were made to and from SLRWH. There were 6 referrals from RHUs and 16 from other hospitals/clinics. Ninety two (92) patients were referred by SLRWH to other health facilities.

The hospital provides Newborn Screening, Immunization (DPT, BCG, Measles, Tetanus Toxoid, Hepatitis B, and OPV) and Family Planning Services such as BTL, OCP, condom use, IUD and DMPA. All postpartum mothers were counselled on Lactational Amenorrhea Method.

They have been an EINC -- friendly hospital since January, and they graduated last August, 2011.

Hospital Director:

Dr. Ma. Isabelita M. Estrella

SLRWH EINC Working Group:

Dr. Ma. Isabelita M. Estrella- OBGYN (OB Site Coordinator)

Dr. Marilou Nery-Pediatrician (Pediatrics Site Coordinator)


Eric Bruno, RN Rosanna Chico,RM Melanie Mariano,RM Mary Ann Legacion, RN Leonora Destacamento, RN


Co-Convener: Dr. Donna Capili Project Staff: Dr. Gemma Gregorio

XII.XI Tondo Medical Center (TMC) The Tondo Medical Center in Manila, Philippines is a 200-bed capacity

XII.XI Tondo Medical Center (TMC)

The Tondo Medical Center in Manila, Philippines is a 200-bed capacity tertiary public medical center established in 1971, under the supervi- sion and control of the Philippine Department of Health (DOH). TMC has eight hospital departments, all of which are currently accredited with their respective specialty societies except for EENT and Pathology which are still in the process of accreditation with the DOH.

Currently located at North Bay Boulevard, Tondo, Manila, Philippines, the tertiary hospital caters to the health needs of patients located in residential and industrial areas near the area.

EINC was introduced to the hospital in January, 2011. Since then, they have been energetically promoting EINC. Their medical director, Dr. Victor dela Cruz has been instrumental in their suc- cess. The hospital is one of the best in the implementation of EINC. They graduated in August and yet continued to promote, held meetings and spread EINC in their catchment areas. Their site coordinators are: Dr. Apple Bandong, Dr. Sheryl Gracilla and Dr. Rodante Galiza.

Hospital Director:

Dr. Victor J. Dela Cruz

Tondo Medical Center EINC Working Group:


Dr. Vanessa Venus Albino (Training Officer)

Dr. Jay-Lanie Co Dr. Joanna Liz M. Fabros


Dr Apple Bandong (Training Officer) Dr. Sheryl Joy Gracilla (Asst Training Officer) Dr. Rocamia Fermin (Chief Resident)


Dr. Gil V. Rabano Dr. Ritche M. Agcaoili


Mrs. Larena Hernandez (OR) Ms. Esmeralda Caliso (NICU) Ms. Erlinda G. Lura (DR) Ms. Jane de Jesus Ms. Maricel C, Serrano Ms. Ma. Laline Verances



Dr. Ina Pelaez-Crisologo Dr. Jessamine C. Sareno

Project Staff:

Dr. Ma. Blesilla Bertos

Dr. Manny Manalaysay Dr. Girlie Larroder Dr.Gemma Gregorio

XIII. EINC Forum Speakers

Maria Asuncion A. Silvestre, MD, FPSNbM, FAAP

Dr. Silvestre is the Convener of a Scale-up Implementation Program for Essential Intrapartum and Newborn Care for the Department of Health and the WHO. She is currently a Consultant of the WHO Country Office in Essential Newborn Care and a Temporary Adviser of the Departments of Making Pregnancy Safer and Child and Adolescent Health, WHO in Basic Neonatal Resuscitation.

Dr. Silvestre graduated from the University of the Philippines College of Medicine (UPCM). She then completed Pediatric Residencies at the Philippine General Hospital (UP-PGH) and also the Children’s Hospital of Michigan. She later completed subspecialty training in Neonatal - Perinatal Medicine at Hutzel Hospital, Wayne State University, Michigan. She is currently an Associate Professor at the UPCM, Consultant Neonatologist at the UPPGH and a corresponding Fellow of the American Academy of Pediatrics and Section of Breastfeeding.

In 2004, she co-authored a Situational Analysis on Newborn Health in the Philippines which shifted her perspectives towards family-centered care of high risk infants. At the core of her thrusts are breastfeeding promotion and lactation support. In 2008, she co-directed the WHO Essential Newborn Care Course (ENCC) here in Manila which motivated her to help address the issues that are plaguing our health care delivery for mothers and newborns.

She served as Technical Reviewer for the WHO documents, “Optimal Feeding of the Low Birth Infant” in 2006 and “Acceptable Medical Reasons for Supplementation” in 2008 and Postpartum and Postnatal Care in 2009. She has co-authored a chapter on “Drugs in Pregnancy and Lactation” in the Pediatric Clinics of North America. She has co-authored a Cochrane Review on Early vs Late Refeeding in Children with Acute Diarrhoea and recent review articles on Health Screening, in the Journal of Clinical Epidemiology. She is Co-Chair of the Breastfeeding Committee of the PGH and conceptualized the Lactation Unit of the Section of Newborn Medicine, UP-PGH. She is a corresponding member of the Section of Breastfeeding of the American Academy of Pediatrics and past Head of the St. Luke’s Medical Center Breastfeeding Working Group.

She is a faculty member of the Asia – Pacific Center for Evidence Based Medicine, and has co- edited/-authored a book entitled “Painless Evidence Based Medicine”, published by John Wiley & Sons, Ltd of the United Kingdom and released in May 2008.

Ma. Cynthia Fernandez-Tan, MD

Dr. Tan is one of the Co-Conveners of the Essential Intrapartum and Newborn Care Scale

up project. She is currently the head of the Gynecologic Oncology Section at the St.

Luke’s Medical Center-Quezon City, Medical Specialist IV Department of Obstetrics and

Gynecology at the Dr. Jose Fabella Memorial Hospital and the Overall Coordinator and

Facilitator of the Basic Emergency Obstetrics and Newborn Care Skills Training Course.

She received her medical training at the College of Medicine – University of the Philippines. She then pursued her residency training in Obstetrics and Gynecology and later on Gynecologic Oncology at the University of the Philippines – Philippine General


She has held various administrative positions as Head, Section of Obstetrics

and Gynecologic Oncology, Chair and Training Officer in the Department of Obstetrics and Gynecology and was designated as Training Officer of the Medical Service in Jose Fabella Memorial Hospital. She was International consultant, ADB Woman and Child Health Development Project, Republic of Uzbekistan.

She has worked with the DOH in various programs as member of the Technical Working Groups on Cervical Cancer Control Program, Adolescent Reproductive Health, Managing Complications of Pregnancy & Childbirth & Basic Emergency Obstetric and Newborn Care. She also was Training Coordinator, Basic Emergency Obstetric and Newborn Care (BEMONC), Dr Jose Fabella Memorial Hospital, designated by the Department of Health as

the Training Center for Luzon. She is a trainer on the Single Visit Approach, Cervical Cancer

Control Program (CECAP).

She is also a member, DOH-WHO Technical Working Group on

Managing Complications of Pregnancy and Childbirth tasked with planning strategies for the adoption of the MCPC in the country and a lecturer on “Adolescent Pregnancy” and “Prevention and Management of Unsafe Abortion in Adolescents” in Trainers’ Training of School and Rural Health Unit Nurses and Guidance Counsellors on Adolescent Reproductive Health conducted by the Department of Education-UNFPA.

Anna Melissa Francesca Tatad-To, MD, FAAP

Dr. Tatad-To is one of the Co-Conveners of the Essential Intrapartum and Newborn Care

Scale-up Project. Among her current positions are the following:

lecturer in Pediatrics and

Neonatology, Ateneo School of Medicine and Public Health Student, mentor in the Ateneo School of Medicine and Public Health, Consultant, Department of Pediatrics, The Medical City, member, Residency Training Unit, The Medical City, coordinator for Pediatrics, Center for Patient Partnership, The Medical City.

Dr. Anna Melissa Francesca Tatad-To completed the INTARMED program at the College of Medicine, University of the Philippines. She then pursued her residency training in Pediatrics in Mt. Sinai School of Medicine at Elmhurst Hspital Center and underwent her fellowship training in Neonatal –Perinatal Medicine in New York Presbyterian Hospital – Weill Medical Center of Cornell, New York.

Dr. Tatad-To’s interest lies in breastfeeding education, promotion and support. She is the adviser and founding member of LATCH (Lactation, Attachment, Training, Counseling and

Help) – a hospital-based breastfeeding training and counseling group. person for magazine articles and online articles on breastfeeding.

She is also a resource

Ma. Lourdes A. Salaveria-Imperial, MD, FPPS, FPSNbM.

Dr. Imperial is one of the Co-Conveners of the Essential Intrapartum and Newborn Care Scale-up Project. She was the head of the Special Care Baby Unit at the American Mission Hospital in Manama, Kingdom of Bahrain. She was also an active consultant in Mary Mediatrix Medical Center, Lipa City, Batangas and in St. Frances Cabrini Medical Center, Sto. Tomas, Batangas.

Dr. Ma. Lourdes A. Salaveria-Imperial completed her medical education at the University of the East, Ramon Magsaysay Memorial Medical Center - College of Medicine. She later underwent her residency in Pediatrics at the University of the Philippines – Philippine General Hospital where she served as assistant chief resident during her last year and later on took her fellowship in Newborn Medicine in the same institution.

Jessamine Mae C. Sareno, MD, DPPS

Dr. Sareno is one of the Co-Conveners of the Essential Intrapartum and Newborn Care. Her

passion in human milk banking and breastfeeding brought her to Meyer Pediatric Hospital,

Florence, Italy where she was trained in human milk banking.

She is the UNICEF consultant

in Human Milk Banking and is the Coordinator for Visayas and Mindanao of the Infant, Young

and Child Feeding, NTWG Ad-Hoc Committee and Committee on Human Milk Bank. She is currently the Medical Adviser and Staff at the University of the Philippines – Philippine General Hospital Human Milk Bank and Lactation Unit.

Dr. Jessamine Sareno obtained her degree of Doctor of Medicine

at the Dr. Jose P. Rizal

College of Medicine- Ateneo de Cagayan-Xavier University. She completed her residency training in Pediatrics at the University of the Philippines- Philippine General Hospital where she also served as the Assistant Chief Resident during her last year. She then pursued fellowship training in Newborn Medicine at the University of the Philippines – Philippine General Hospital.

Teresita S. Cadiz- Brion, MD, MHPEd, FPOGS

Dr. Brion is one of the OB Co-Conveners of the Essential Intrapartun and Newborn Care Scale- up Project.

She is a Senior Active Consultant at the St. Luke’s Medical Center and Ospital ng Maynila Medical Center, Visiting Consultant in Dr. Jesus Delgado Memorial Hospital, United Doctors’ Medical Center, Mary Chiles General Hospital. She is also the Head, Subcommittee on Training, Breastfeeding Working Group, St. Luke’s Medical Center, Core Member, Menopause Clinic, St. Luke’s Medical Center. She is an Associate Professor, Dept. of Obstetrics and Gynecology, Pamantasan ng Lungsod ng Maynila (PLM) College of Medicine.

She has held various positions in the academe namely: Associate Dean, St. Luke’s Medical

Center- William A. Quasha College of Medicine, Assistant Dean, PLM College of Medicine,

Director, MEDICS (Medical Education Unit), PLM College of Medicine, Director, Skills Laboratory, St. Luke’s College of Medicine, and Chairman, Department of Obstetrics and Gynecology- PLM College of Medicine.

Dr. Teresita S. Cadiz-Brion obtained her degree of Doctor of Medicine at the University of the Philippines. She completed her residency training and served an extra year as chief resident in Obstetrics and Gynecology at the Ospital ng Maynila Medical Center. She then pursued further training in pelvic ultrasound, hysteroscopy and laparoscopy.

Ernesto S. Uichanco, MD

Dr. Ernesto Uichanco is one of the Co-Conveners of the Essential Intrapartum and Newborn Care Scale-up Project. He is currently Professor, College of Medicine, University of the Philippines (UP) Manila, a member of the Admissions Committee, University of the Philippines- College of Medicine, Attending Obstetrician-Gynecologist, Philippine General Hospital (PGH), active consultant, Section of Maternal -Fetal Medicine, Department of Obstetrics & Gynecology, UP-PGH Med. Center; Consultant, Ultrasound Section, Department of Obstetrics and Gynecology, UP-PGH Medical Center; Member, Breastfeeding and Lactation Management Committee, Philippine General Hospital; Medical Specialist III, Department of Obstetrics and Gynecology, East Avenue Medical Center; Active Consultant, Dept. of Obstetrics and Gynecology, St. Luke’s Medical Center; Visiting Consultant, University of the Philippines Diliman Health Service.

Dr. Ernesto Uichanco obtained his degree of Doctor of Medicine at the University of the Philippines. He completed his residency training in Obstetrics and Gynecology University of the Philippines Manila –Philippine General Hospital and pursued fellowship in Perinatology at the same institution. He then went to Japan as a clinical research fellow in obstetrics and gynecology in Dokkyo University School of Medicine and Clinical research fellow in obstetrical ultrasonography and Doppler velocimetry in Kobe University School of Medicine.

He has held various positions such as Chief of Section, Section of Maternal and Fetal Medicine, Department of Obstetrics and Gynecology, UP-PGH Medical Center; Member, Board of Directors, Philippine Society of Maternal-Fetal Medicine, Member, Editorial Board, Journal of the Philippine Obstetrical & Gynecological Society, Inc., Member, Editorial Board of the Journal of the Perinatal Association of the Philippines. He was awarded the Mercedes Vida Planas Professorial Chair, Jose R. Katigbak Professorial Chair, Commended as among “Gawad Pagkilala: UP Manila Achievers” in the 89th UP Manila Foundation Week Celebration, Philippine Medical Association Raul Rivas Research Award.

Fay S. de Ocampo, MD, DPPS

She is one of the Co-Conveners of the Essential Intrapartum and Newborn Care. She is presently a practicing neonatologist at the Marian Hospital, Sta. Rosa Laguna, She is also a part-time neonatologist at the Sta. Ana Hospital. Dr. Fay de Ocampo received her medical degree from the College of Medicine – Pamantasan ng Lungsod ng Maynila. She then

pursued her residency training in Pediatrics and fellowship training in Newborn Medicine at the UP-PGH.

XIV. Bibliography

Sobel HL, Silvestre MAA, Mantaring JBV, Oliveros YE, Nyunt-U S. Immediate newborn care practices delay thermoregulation and breastfeeding initiation. Acta Paediatrica 2011. Aug;100(8):1127-33.

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

Sobel HS, Silvestre MA, Catibog HI. Obstetric practices in fifty-one large hospitals in the Philippines need to realign with the evidence-base: An observational study. 2009. Unpublished.

WHO. Newborn care until the first week of life: clinical practice pocket guide. World Health Organization 2009. (Last accessed Oct 30, 2010 at htm)

Sobel HL, Silvestre MA, Vitangcol B, Mantaring JB, Soe Nyunt-U. The association between immediate newborn care practices and neonatal mortality, sepsis and severe disease in a Philippine hospital. Submitted for publication.

Darmstadt GL, Bhutta Z, Cousens S, Adam T, Walker N, de Barnis L. For the Lancet Neonatal Survival Steering Team. Evidence-based, cost-effective interventions: how many newborn babies can we save? Lancet, 2005;365:977-88.

WHO. Department of Making Pregnancy Safer. Integrated Management of Pregnancy and Childbirth. WHO Recommended Interventions for Improving Maternal and Newborn Health. 2007.

Darmstadt GL, Walker N, Lawn JE, Bhutta Z, Haws RA, Cousens S. Saving newborn lives in Asia and Africa: cost and impact of phased scale-up of interventions within the continuum of care. Health Policy and Planning, 2008. 23 (2):101.