WHO-Western Pacific Region:

Howard Sobel MD, MPH,

Translating Evidence into

Country Action
10-12 April 2015

Reproductive, Maternal, Newborn, Child

and Adolescent Health Programme
Coordinator

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

Dr Hoang Tran, Da Nang Hospital for

Women and Children

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

Trends- Deliveries assisted by trained health staff

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

Major causes of death in neonates and children underfive in the Western Pacific Region - 2012

Neonatal
deaths: 56%

Source:

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

Every 2 minutes, 1 newborn dies

in the Western Pacific Region

231 000 neonatal deaths in the Western

Pacific Region every year

1 represents 100 neonatal deaths

WHO Global Health

Observatory, 2011

Philippines:
documenting
the problem

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

If this benefits
babies,

Immediate drying,
delayed cord clamp

Skin-to-Skin Contact

Why is this so
common?

Immediate cord clamp,

delayed drying, suction

Separated from mother

Intrapartum Care

All

First
Embrace

Labour Monitoring
(Partograph)
Intrapartum care

Newborn Care

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

Routine care eye care, vitamin

K, immunizations, weighing and
examinations afterwards

At Risk

Preterm Labour
Preterm
Eliminate unnecessary
and
inductions &C-section
Low Birth Antenatal steroids
Weight
Antibiotics for
pPROM

Sick
Newborns

Obstructed/Prolonged
Labour, Foetal Distress

Assisted delivery
C-section

Kangaroo Mother Care

Breastfeeding support
Immediate treatment of
suspected infection

Not breathing at birth

Resuscitation
Suspected sepsis
Antibiotic treatment

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

KHM

CHN

LAO

MNG

PNG

PHL

SLB

VNM

Newborn situation analysis

+++

+++

+++

+++

+++

+++

+++

+++

EENC Action Plan

+++

+++

+++

+++

+++

+++

+++

+++

EENC Action Plan costed

+++

+++

+++

No

+++

+++

+++

EENC technical working /

coordination group formed
Full-time EENC/newborn
MOH focal person identified
EENC stakeholder group
organized to engage political
leaders and champions
Clinical Protocol adapted
Consensus-building
workshop
Mechanisms established to
ensure professional assoc
membership implement
EENC

+++

+++

+++

+++

+++

+++

+++

+++

+++

No

+++

No

+++

+++

+++

++

No

++

+++

No

++

+++

No

+++

No

+++

+++

++

+++

++

+++

+++

+++

+++

++

+++

No

+++

++

+++

+++

No

No

Benchmark

+++ Yes, Done ++ On-going/Partial, + planned

no

Regional tools to support countries to

change practitioner behaviour
Modules for EENC
National Situation Analysis and
Action Planning
Clinical Practice Pocket Guide
Health Facility Strengthening
Coaching (Facilitator Guide)
Annual Implementation Review and
Planning
Monitoring and Evaluation
Communications: Info kits, promotional
videos, website
www.thefirstembrace.org

Viet Nam Full Speed Ahead

Regional tools to support countries to

change practitioner behaviour
Modules for EENC
National Situation Analysis and
Action Planning
Clinical Practice Pocket Guide
Health Facility Strengthening
Coaching (Facilitator Guide)
Annual Implementation Review and
Planning
Monitoring and Evaluation
Communications: Info kits, promotional
videos, website
www.thefirstembrace.org

Planning process for EENC

June-Aug 2013

Bottleneck Analysis conducted

May- July 2014

Additional pre-plan info collected

Sep 2014 Jan

2015

National consultations on EENC

National Action Plan for 2014-2020

Dec 2014

Adoption by MOH
Part of Master Plan on RMNCH

2014-2015

Mobilizing resources for supporting

implementation

Establish Stakeholder Coordination

MOH and WHO initiated process
Government: MOH, national and regional,
provincial and district hospitals
UN agencies: WHO, UNICEF
INGOs: A&T, Save Children, Plan
International, World Vision
Reproductive Health Technical Group

Current progress

National guidelines on EENC approved by MOH

National Action Plan on EENC developed
Clinical Pocket book adapted
Three Centres of Excellence initiated:
EENC support team formed
Health staff coached on EENC
Health Facility Strengthening approach introduced

124 provincial facilitators trained

About 3000 health staff of provincial level
coached on EENC

Regional tools to support countries to

change practitioner behaviour
Modules for EENC
National Situation Analysis and
Action Planning
Clinical Practice Pocket Guide
Health Facility Strengthening
Coaching (Facilitator Guide)
Annual Implementation Review and
Planning
Monitoring and Evaluation
Communications: Info kits, promotional
videos, website
www.thefirstembrace.org

Update clinical protocol

(July 2014 April 2015)
Local expert team established
WPRO pocket book translated into local
language
Technical workshop to review the pocket
book with TA from international consultant
Finalization
Formatting, printing and distributing

Regional tools to support countries to

change practitioner behaviour
Modules for EENC
National Situation Analysis and
Action Planning
Clinical Practice Pocket Guide
Health Facility Strengthening
Coaching (Facilitator Guide)
Annual Implementation Review and
Planning
Monitoring and Evaluation
Communications: Info kits, promotional
videos, website
www.thefirstembrace.org

Why do traditional training-based

approaches not change practice?
Do not start with understand the larger context
Assume participants have no previous
knowledge;
do not identify & start with health worker beliefs

Do not change systems in which health workers

operate
Do not affect facility policies which support
incorrect or harmful practices
Do not change attitudes of senior decisionmakers, often based on outdated standards

How is coaching different?

2-day coaching in a delivery room creates
a realistic environment
No lectures
Health workers demonstrate their current
practices unassisted to establish baseline
Facilitators coach participants until
newborn care steps are mastered
Pre- and post-coaching evaluations of
clinical practice, knowledge and hand
hygiene ensure participants meet minimum
standards
20

Hand Hygiene Pre and Post

Tests
Draw an outline of both
hands (front and back) on
A4 paper.
Rub Glow Germ all over
hands.
Wash their hands.
Shine UV Light onto their
hands.
Mark areas with Glow
Germ still present on the
hands outlined on the A4
paper.

WHO Western Pacific Regional Office

Checking equipment
Setting up newborn resuscitation
area

No more waiting until a non-breathing baby to set up

resuscitation area and find leaking equipment

22

Setting up delivery space,

dry towel on bare abdomen

Left-handers discover it is easier if the equipment is

on the left side

23

Dry baby, remove wet cloth, put in

immediately in skin-to-skin contact,
and cover with dry cloth

Every participant has to demonstrate supervised

drying alone and as part of sequenced actions

24

Clamp and cut the cord once after

pulsations stop

No more unnecessary separations and exposure to dirty

surfaces needed for trimming the cord
25

Counseling mothers on feeding

cues
Babies will be ready
to breastfeed when
they show the
following signs:

Drooling
Mouth opening
Tonguing/licking
Rooting
Biting hands/fingers
Crawling

No more forced breastfeeds

26

Practicing Bag and Mask Ventilation

for non-breathing babies (after
thorough drying)

Each movement of health workers are examined.

Unnecessary movements are eliminated so that chest
rise can happen in the golden minute

27

Results of Coaching, 6 countries

28

Status of INC coaching in

Cambodia (June, 2014)
100%
90%
80%

30%
47%

70%
60%

Staff not trained

Staff trained

50%
40%
30%

70%
53%

20%
10%
0%

Referral hospitals

Health centers

Results of Coaching
Staff usually dont want to go back to the next day, but they
were excited to continue -- Viet Nam
After practicing the new approachthe babies are
stronger, they breathed better than the other approach; they
turned pink faster-- Cambodia
The delivery room was quiet The babies were so quite,
we were worried. We prodded them to make them cry to
make sure they were ok -- Mongolia
Oh, that feels so good, thank you doctor--Philippines
That was the first time I was thanked --Philippine doctor
Thank you doctor for bringing this to my countryViet Nam
Until this coaching, I thought of newborns as specimens
needing things to be done; now I realize they are highly
emotional beings Solomon Islands
30

Da Nang Hospital for Women and

Children, Viet Nam: Translation of
National and International
Guidelines into local action

NNG

Surface area: 1257,3km2

Population: 1 million
Hospital catchment: 10 million
Hospital births:~15,000

Timeline of Events in Da Nang Hospital, Viet Nam

2014
May

Da Nang Health Department and A&T discussions

Attending EENC WHO/UNICEF workshop
Training key staff

First EENC case for normal delivery 5/7/2014

JunJul

AugSep

Training more staff with A&T financial support

Being trained by WHO and MOH

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

EENC for all applicable C-section baby 20/10/2014

OctNov

Training for staff with A&T financial support

Decree and EENC guidelines from MOH

2015
JanMar

Training staff with WHO support on health facility strengthening and

M&E
Reinforcement of EENC activities

Coaching results and extent in central region

20 hospital staff were trained to be EENC facilitators
EENC facilitators coached
185 hospital staff
86 health professionals from other Da Nang
hospitals
90 health professionals in Quang Nam Province
Monitoring trips to Gia Lai, Quang Ngai province

Normal delivery
600

500

478
459

539
533

489
468
401

400

377

382
369

334
305

300

200

100

Sep

Oct

Nov

Total

Dec

S2S

Jan

Feb

C-section
1000
900

877
760

800

741

696

700

671

656

691

576

600

546
500
400
300
200

159
100
0
Oct

Nov

Dec

Total

Jan

S2S

Feb

Outcome

As compared to the 2 previous Csections, I found warmer, happier and

more satisfied to be with my baby
Midwife We now do not use much
resuscitation area as baby and mother are
well themselves

After C-section for twins

Outcome
Before EENC

After EENC

8.3
8

6.8

6.6
5.7

5.3

5.5

5
4

3.2
3

2.5

2.7

2.7

2
1
0
NICU admission % of
livebirths

Antibiotic use % of
livebirths

Death of livebirths

Exclusive breastfeeding Exclusive breast feeding

on discharge per 10
per 10 randomly babies
babies in neonatal unit
in normal nursery

Gaps found during health facility

strengthening process
High C-section rate
Formula feeding during hospital stay
Short period skin-to-skin for two-thirds
babies with normal delivery
Resuscitation areas not in operating
theatre

Next steps
Continue regular meetings
Perform monthly exit interview and
observation with checklist
Solve problems
Train staff in hospitals in the regions
Monitor other hospitals
Establish EENC team for the region
Make use of public media
Attract support from all possible sources

Regional tools to support countries to

change practitioner behaviour
Modules for EENC
National Situation Analysis and
Action Planning
Clinical Practice Pocket Guide
Health Facility Strengthening
Coaching Session Facilitation
Annual Implementation Review and
Planning
Monitoring and Evaluation
Communications: Info kits, promotional
videos, website
www.thefirstembrace.org

Using evidence to inform practice:

Health facility data collection in the
Philippines

EENC in the Philippines

National Action Plan for EENC
adopted and costed in 2013
WPR EENC M&E Framework pilot
led by DoH
Data collection forms sent to
facilities implementing EENC
On-going guidance provided to
facilities, visits made
Data being entered into webbased DHIS 2 or Excel
Pilot in April & May 2015
Source: Wikipedia map, 2015

EENC in the Philippines

Facilities included in the EENC M&E Framework Pilot
Facility Level

Total,
#

DOH (National
Capital Region)
DOH Regional
NCR LGU and
military hospitals

10

Provincial and
Chartered City
Hospitals

Implementing EENC facilities

EENC,
included in pilot,
# (%)
# (%)
8 (80%)
8 (100%)

47
25

39 (83%)
20 (80%)

39 (100%)
?

105

87 (83%)

Philippines EENC Coverage Indicators

Coverage measure
% of live births attended by skilled health
personnel
% of live births that take place at health facilities
% of live births delivered by caesarean section
% of live rural births delivered by caesarean
section
% of newborns breastfed within one hour of birth
% of live births with a reported birth weight
% of women who received postnatal care within
two days of birth following discharge from facility
% of newborns receiving postnatal care within
two days of birth following discharge from facility
Source: NDHS 2013
*By skilled providers (doctors, nurses, midwives) only

2014 Target
2020
72.8% 90%
61%

90%

9.3% 5-15%
7.6% 5-15%
49.7% 100%
80.1% 100%
70.1%* 80%
52.6%

80%

EENC M&E in the Philippines

Impact Indicators for Newborn Health
Data
required

Indicator

2014

Neonatal mortality rate (per 1000 LB)

Perinatal mortality (per 1000 LB)

13
22

Proportional causes of NN death:

Neonatal
Sepsis
deaths
Birth asphyxia
Complications of pre-term birth
Prematurity/ Prevalence of low birth weight
(<2500g)
Low birth
weight
Prevalence of pre-term birth (< 37
weeks)
Source: NDHS 2013

?
?
?
21.4%
2.6%

Regional tools to support countries to

change practitioner behaviour
Modules for EENC
National Situation Analysis and
Action Planning
Clinical Practice Pocket Guide
Health Facility Strengthening
Coaching Session Facilitation
Annual Implementation Review and
Planning
Monitoring and Evaluation
Communications: Info kits, promotional
videos, website
www.thefirstembrace.org

Review & Planning Process

May 2015
14 national and sub-national hospitals will be visited to
observe practice, review charts & interview mothers and
staff

Twelve-Month Detailed Implementation Plan for

Early Essential Newborn Care, PHL, 12/3/2013
Activity

Actions

Responsible

Timing

Develop Terms of Reference.

Agree on membership (proposal: Dr
Bounnack to chair, MCH, Dept Training
and Research, Dept Hygiene and
Health Promotion, National Hospital
representatives (Mitaphap,
Sethathirath, Mahosoth, Mother and
Newborn Hospital), WHO, CICH,
UNICEF, UNFPA, Save the Children,
Pediatric Society, Obstetric Society,
representatives of midwives, nurses).
Develop and pass decree.
Monthly meetings; intense follow up
between meetings
Development of timelines, annual
reviews and operational plans.

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

January 2014 decree

Validation of worksheets on policies

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

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

January 2013

Presentation of the regional clinical pocket guide (CPG) to

Steering Committee.
Identify sub-group who will work on the local adaptation.
Adaptation by sub-group.
Translation of first draft adaptation.
Visit by Dr. Mianne Silvestre to coordinate final review of
adapted and translated guidelines.
Stakeholder reviews of adapted version.
Report progress to the Steering Committee and finalization of
CPG
Complete translation back translation consensus on final
version
Format, produce and print final consensus version

Eunyoung

January February
2014 final translated
version agreed

Identify group who will be responsible for initial work and

planning the scale up in 2 national hospitals; get approval from
hospital directors
Field visit to Philippines EENC sites + implementation
training
Begin process of early implementation into hospitals
(Adapt/translate EENC implementation training
materials/course guidelines; adapt/translate EENC
implementation guide based on existing PHL version
including monitoring and evaluation indicators; adapt/translate
resource person training guide; train hospital teams

Eunyoung

1.Establish
Steering
Committee

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

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

4.Health Facility
Strengthening for
EENC

Tiengthong

Formatting, printing,
production
February April 2014

Phommady Vesaphong
(MCH)
Mahosot ( TBD)
J. Murray/M. Silvestre

Oct 6-11- 2-3 staff

visit PHL for EENC
training and field
visits
Begin adaptation of
EENC
implementation
materials and
guidelines
February/March
2014 June 2014

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

Local consultant reviews pre-service curricula and in-service

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

MOH: Dr. Saiyadeth

Local consultant to make
edits/changes nd to
coordinate review meetings
Eunyoung

January 2014 May

2014 review
June 2014
December 2014
consultative process

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

Map existing materials

Adapt and translate for Lao context
Print and produce materials

Eunyoung
WHO/WPRO

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

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

Develop social marketing approach

Develop messages, materials, media
Begin implementation of social marketing approach
coordinated with hospital implementation

MOH:
Eunyoung
WHO/WPRO
Menzies/Merritt

Approach and
materials - May 2014
onwards

8. Conduct EENC
program
implementation
review early
implementation
hospitals

Develop method, materials and indicators

Conduct review
Use data to make program decisions

MOH and UNICEF to lead stakeholders for planning for

legislative development.
MOH-UNICEF drafting of the legislation with participation from
WHO + Save the Children
WHO to support developing briefing materials
?Role of Ministry of Culture and ?

MOH
UNICEF
WHO

Regular updates of
Steering Committee
from UNICEF and
WHO 2014

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

it.

Sommana Rattana

Discuss with Dr.

Bounnack

9.Strengtheni
Code on
Marketing of
Breast-milk
Substitutes

10.Institutionalizin
g BFHI+
accreditation

Implementation
July 2014 onwards

MOH:
J Murray/M Silvestre
Eunyoung
WHO/WPRO

Method, materials,
indicators
September 2014
Conduct review
November 2014

1. Establish Steering Committee

2. Finalize the Newborn Action Plan
3. Local adaptation of the Clinical
Pocketbook for EENC
4. Health facility strengthening
5. Review and revise pre/in-service
training curriculae
6. Develop EENC information tool kit
7. Implementation review
8. Enforce Milk Code
9. Strengthening MBFHI/accreditation