1. Newborn Resuscitation Steps

BackgroundBetween 1990 and 2011, global neonatal mortality decline was slower than that of under-five mortality. As a result, the proportion of under-five deaths due to neonatal mortality increased. This increase is primarily a consequence of decreasing post-neonatal and child under-five mortality as a result of the typical focus of child survival programmes of the past two decades on diseases affecting children over four weeks of age. Newborns are lagging behind in improved child health outcomes. The aim of this study was to conduct a comprehensive, equity-focussed newborn care assessment and to explore options to improve newborn survival in Indonesia, Lao People’s Democratic Republic (PDR) and the Philippines.

ResultsMain findings: (1) In the three countries, decline of neonatal mortality is lagging behind compared to that of under-five mortality. (2) Comprehensive newborn policies in line with international standards exist, although implementation remains poor. An important factor hampering implementation is decentralisation of the health sector, which created confusion regarding roles and responsibilities. Management capacity and skills at decentralised level were often found to be limited. (3) Quality of newborn care provided at primary healthcare and referral level is generally substandard. Limited knowledge and skills among providers of newborn care are contributing to poor quality of care.

(4) Socio-economic and geographic inequities in newborn care are considerable. BackgroundWorldwide neonatal mortality (deaths during the first 28 days of life) has declined 32% from 32 deaths per 1,000 live births in 1990 to 22 per 1,000 live births in 2011.

However, this decline is slower than that of under-five mortality for the same period. Between 1990 and 2011, global under-five mortality dropped on average 2.5% per year while neonatal mortality declined 1.8% annually. As a result, worldwide the proportion of under-five deaths due to neonatal mortality increased, from 36% (4.362 million) in 1990 to 43% (2.955 million) in 2011. This increase is primarily a consequence of decreasing post-neonatal (deaths after 29 days of life and before age one) and child mortality (deaths between age one and age five) in children under five from infectious diseases such as measles, pneumonia, diarrhoea, malaria, and AIDS ,. Child survival programmes have typically focused on these diseases affecting children over four weeks of age, resulting in a larger reduction in mortality in this group of children compared to the newborn group ,.

These findings urge the need for focus on newborn health, as newborns are those lagging behind in improved child health outcomes.The leading causes of neonatal death globally are complications of preterm birth, intra-partum related causes and sepsis or meningitis ,. The majority of these neonatal deaths can be prevented with known, low-tech and effective interventions such as improved hygiene at birth, exclusive breastfeeding, newborn resuscitation, management of newborn infections and simple approaches to keeping babies warm ,.We hereby present the results of the newborn needs assessment we conducted in Indonesia, Lao People’s Democratic Republic (PDR) and the Philippines. Its objective was to conduct a comprehensive, equity-focussed assessment and to explore options to improve newborn survival. An independent team of researchers conducted the study on behalf of UNICEF East Asia and Pacific Regional Office. Study settingThis study took place in Indonesia, Lao PDR and the Philippines, three countries located in South-East Asia.Countries located in the UNICEF East Asia and Pacific region, having a high neonatal mortality proportion among their under-five deaths and, having not yet achieved Millennium Development Goal 4 (aiming to reduce the under-five mortality rate by two-thirds between 1990 and 2015) were defined as being eligible to participate in this study. Participation of eligible countries was discussed with respective government counterparts and Indonesia, Lao PDR and the Philippines accepted to take part in this study. Some newborn health-related indicators of these three countries are given in Table.

Study set-upWe assessed newborn health policies, services and care and the equity of these services and care in the three countries through document review, semi-structured interviews and health facility visits.The document review included national policy documents, newborn health guidelines, routinely collected data, reports on newborn health status and scientific papers published in peer reviewed journals. Documents related to maternal and newborn care were collected using library and web-based search engines. We used PubMed to search for peer reviewed papers, and Google and Google Scholar to find grey literature. Documents and papers found as such were supplemented with documents provided by the UNICEF advisors and programme staff at the regional and country offices.In each country we conducted interviews with key informants including policy makers at national, provincial and district level, representatives of health professional organisations, United Nations organisations, bilateral and multilateral development agencies, non-government organisations and civil society organisations, healthcare providers in the public and private sector, and mothers. In Indonesia, four policy makers in newborn health and managers belonging to government institutions, and 26 belonging to other organizations, were interviewed. In PDR these were seven belonging to government institutions and 14 to other organizations and in the Philippines eight and ten respectively.

In each of the visited health facilities we conducted several interviews with providers (doctors, midwives, nurses and community health workers/village midwives attached to the health facility) and mothers. These were brief interviews focussing on the providers’ work with newborns and their comments and perception regarding the situation and care of the newborns. The interviews with mothers focussed on their perception and satisfaction with the provided newborn care. An interview guide was developed and used during the interviews. The interviewers took notes of the answers given.Per country, between four and eight health facilities, including primary healthcare and referral facilities, were visited in both rural and urban areas.

Only facilities providing antenatal, childbirth and postpartum services for mother and newborn and corresponding national norms regarding medical infrastructure, equipment and staffing, were eligible to be selected for these visits. The regions and facilities were selected by the researchers with inputs from the national UNICEF staff and the respective ministries of health. The main objective of these visits was to observe the conditions for newborn care and its implementation and to talk with healthcare providers and clients about newborn care. As standard for good newborn care and services we used the available national newborn policies and guidelines which are based on internationally recommended policies and guidelines. At each facility we checked if commodities and drugs needed for newborn care were available, and if providers knew the kind of routine newborn care they have to provide, how to manage and treat complications occurring in newborns and how to conduct emergency newborn care. Data collection and analysisThe document review was conducted in November 2012, the interviews and health facility visits took place in November and December 2012.

The document review, interviews and health facility visits were conducted by an independent team of researchers consisting of five medical doctors with public health and MNCH background and one health economist. Three of the researchers were European, three came from the respective Asian countries included in this study.Quantitative data found by document review and review of available data were organised in tables and interpreted in the frame of the newborn care assessment. The qualitative findings from the document review, interviews and health facility visits were triangulated to describe newborns’ health status, the health policy and the health system context for newborn care, and the equity situation regarding newborn care and services. The analysis was based on the ‘six building blocks’ of a health system as defined by the World Health Organisation: (1) service delivery, (2) human resources, (3) essential medicine and technologies, (4) health financing, (5) health information systems, and (6) governance and leadership. EthicsUNICEF East Asia and Pacific region representatives discussed participation of eligible countries with the respective government counterparts and only those that accepted to participate in the assessment were included. None of these countries required ethics approval from the government for this study.

Most likely because this assessment was not categorised as primary research as the research was based on readily available data and documents. Oral informed consent was obtained from all key informants before enrolment in the study. ResultsDuring the previous two decades, insufficient progress has been made in reducing neonatal mortality in Indonesia, Lao PDR and the Philippines (see Table ). The neonatal mortality rate (NMR), defined as numbers of deaths in the first 28 days of life per 1,000 live births, is at present 32 deaths per 1,000 live births in Lao PDR, 19 deaths per 1,000 live births in Indonesia and 16 deaths per 1,000 live births in the Philippines -.

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Neonatal mortality has slowly been decreasing in the three countries since 1990 but, in line with what is observed globally and due to the same reasons, namely greater focus on and better results in improving health of children older than one month, this decline is lagging behind the decline of under-five mortality. There is still insufficient insight in the causes of mortality, as neonatal and perinatal death audits are not or not regularly enough conducted.

In Lao PDR and in the Philippines a system for perinatal and neonatal death audits does not exist. In Indonesia a system exists, however it is poorly implemented and audits are not performed systematically. 5 year periodsPercentages decrease between 1990- 1994 and most recent mortality rate1990- 19941995- 19992000- 20042005- 20092010- 2012IndonesiaNeonatal mortality rate.37%Under-5 mortality rate.51%Lao PDRNeonatal mortality rate41%Under-5 mortality rate067954%PhilippinesNeonatal mortality rate18181716-11%Under-5 mortality rate54484034-37%WorldNeonatal mortality rate32-2231%Under-5 mortality rate39%. Sources ,-,-.numbers of deaths in the first 28 days of life per 1,000 live births.numbers of deaths before reaching the age of five per 1,000 live births.Despite the still relatively high neonatal mortality, national comprehensive newborn policies in line with international standards exist in the three countries.

Table gives an overview of the documents identified and reviewed as part of this assessment. Policies, strategies, guidelines and legislation published during the last two decennia directly related to and relevant for maternal, newborn and child health (MNCH) were included. Most policy makers and health managers interviewed mentioned that the implementation of these policies and guidelines remains poor. Providers often mentioned that they were not aware of the availability of these guidelines and do not know what kind of newborn care they are supposed to provide. Key informants often stated the decentralisation of authorities and relegation of responsibilities to provincial, district and municipality levels as an important factor hampering the implementation.

They mentioned that decentralisation created confusion regarding the roles and responsibilities for newborn care in health management, including in financing, planning and implementation. Interviews and reviewed reports also made it clear that management capacity and skills at provincial, district and municipality level were often limited and are as such jeopardising the implementation of good quality newborn care.

Nevertheless, lots of key informants were positive regarding decentralisation, mentioning that decentralised health systems bear lots of opportunities such as the possibility to tailor healthcare to the local context and needs. Decentralisation of the health system was initiated in the Philippines in 1991, in Indonesia in 2001 and in Lao PDR in 2005. YearPolicies, strategies, guidelines and legislationsIndonesiaRelevant for maternal, newborn and child health2010-2014Health Strategic Plan 2010 – 2014 – MoH (HEALTH MINISTER DECREE NO. 021 / MENKES / SK / I / 2011)2005-2025National Long‒Term Development Plan (RPJPN 2005‒2025) (Based on Law No. During interviews, many health policy makers and managers mentioned that in spite of the availability of health facilities providing good newborn care, the overall quality of newborn care was a major concern.

They mentioned that substandard quality of care was a problem at primary healthcare and referral level. This was the case for routine newborn care, for case management of the sick newborn and for emergency newborn care. As important reasons for the poor quality they identified limited knowledge and skills for newborn care of health workers at all levels. These conclusions were confirmed by the findings of providers interviews, observations made during the health facility visits and available data on quality of care -,. Many providers interviewed were unable to tell what kind of essential newborn care has to be provided.

In some of the visited health facilities newborn resuscitation equipment was not available. Although routinely collected data on quality of newborn care was hard to be found, the available data shows room for improvement of newborn care quality (see Table, two last indicators). In this context, key informants at national, regional and district level often mentioned that supervision and mentoring of health staff, generally recognised as being important in delivering and maintaining good quality of care, was rather poor.Data and results from reviewed reports and papers show that access to skilled health workers, mainly in rural and remote areas, remains limited, not only due to unequal distribution or lack of health staff and financial and geographic barriers but also because of local beliefs and practices -. This was also mentioned by policy makers, managers and health providers interviewed. We found the following data regarding the number of available skilled health workers: in Indonesia there are 19.9 healthcare professionals per 10,000 population (although this is believed to be an underreporting of the real situation as data from the private sector and from hospitals belonging to other ministries are not included) , in Lao PDR there are 8.2 healthcare professionals per 10,000 population and in the Philippines 10.3 medical doctors, 15.5 midwifes and 40.0 registered nurses per 10,000 population.

In Indonesia and the Philippines there are sufficient midwives, nurses and medical doctors but most reviewed reports and consulted key informants stated that the unequal distribution of these health providers disadvantages the difficult to reach areas. Staff retention in these areas was identified to be challenging -. Apart from the unequal distribution and retention problems, overall workforce shortage is an additional problem in Lao PDR.Based on findings from the document review and from interviews with key informants, we found that local practices, beliefs and myths, especially in Indonesia and Lao PDR, were influencing maternal and newborn health seeking behaviour -. Traditional birth attendants still have an important position in providing newborn care, especially in rural areas ,.Geographic accessibility to newborn care is an issue especially for people living in remote and difficult to reach areas. In Indonesia and the Philippines providing care at all islands is not easy to organise, while in Lao PDR reaching communities living in very remote areas without roads is challenging. Approaches to overcome the gaps in geographic accessibility are implemented, such as the deployment of village midwives in Indonesia and the establishment of village health stations and community health teams in the Philippines, although challenges in accessibility remain ,-.Strategies to reduce or eliminate financial barriers to newborn care exist in the three countries.

In the Philippines and Indonesia respectively, premium- and tax-based national health insurance schemes covering newborn care for respectively the poor and for all citizens are in place -. In Lao PDR the government recently approved a policy for free delivery and care for children under five years of age. Despite these strategies, financial barriers to newborn care remain. For example, the fact that transport costs are not covered by the insurance schemes in Indonesia and in the Philippines is a barrier to care for the poor and for those living in remote areas where transport costs can be high ,. In Lao PDR an exact roll-out plan for the free of charge policy and the required budget were not yet available at the time of the country assessment.The above findings on socio-cultural, geographic and financial access to newborn care are directly linked to the socio-economic and demographically observed inequities in newborn care.

As Table shows, neonatal mortality varies depending on socio-economic and geographic background. Mortality rates are highest among the most disadvantaged with higher rates found in the lowest wealth quintiles, among the less educated women and among rural residents -. Source -.Coverage of newborn care shows the same inequities. For most care, such as early initiation of breastfeeding, newborns weighed immediately after birth and BCG vaccination, the coverage declines with lesser education and wealth level and is lower in rural areas compared to urban areas -.

Lower coverage in the rural areas is also reinforced by the overrepresentation in the rural and more remote areas of a less educated and poorer population. The inequities in newborn care coverage are considerable despite the introduction of several initiatives and programmes such as the village midwifes initiative in Indonesia and insurance schemes introduced in Indonesia and the Philippines.Finally, we would like to mention two important findings regarding health sector organisation jeopardising newborn care. Firstly, fragmentation of newborn care across several ministry of health departments in the three countries hampers prioritisation and efficient coordination and implementation of newborn care. And secondly, despite the importance of the private health sector in Indonesia and the Philippines, governmental regulation of and cooperation with this sector is weak. This may have a negative impact on newborn care and is also a missed opportunity to improve access to care.

DiscussionSimilar challenges for newborn care were identified in Indonesia, Lao PDR and the Philippines and show the need to improve access to quality newborn care. Opportunities identified to address this need include: (1) strengthening leadership and skills of health management, (2) improving quality of newborn care and (3) minimizing socio-economic and geographic inequities. Need for improvement of the quality of newborn care and for addressing the inequities in newborn care were also expressed in several recent studies ,.Improved leadership and governance may enhance the implementation of newborn policies and improve the quality of care provided at the facilities. Clear responsibilities and roles of authority for all departments and all administrative levels therefore need to be defined.

Additionally, management skills and capacity in planning, budgeting, and supervision at provincial, district and municipality level need to be improved.Although evidence-based, cost-effective interventions for newborn care are known, the implementation of good quality newborn care remains a problem ,-. A precondition for health workers to provide good quality newborn care is that they receive high quality training. Guaranteeing quality pre- and in-service training in newborn care for all levels of health workers is crucial. This implies the existence of well-functioning accreditation, standardisation, regulation and monitoring systems of the training institutions which was identified in Indonesia as currently rather weak or missing. In recent years, Lao PDR and the Philippines have invested a lot in improving pre-and in-service training on maternal, newborn and child health ,.

Despite this we found that, similar to other studies from the region, knowledge and skills to provide good quality newborn care were missing ,. Special attention is needed to ensure that adequate skills training, including practice with patients, is part of the curricula. Another important although often neglected or poorly implemented tool to maintain and/or improve quality of care, is supportive supervision conducted at health facilities ,.Having enough professional health workers equally distributed in the country is another requirement for providing good newborn care. While there is no gold standard for the sufficiency of the health workforce, WHO estimates that countries with fewer than 23 healthcare professionals (counting only physicians, nurses and midwives) per 10,000 population will be unlikely to achieve adequate coverage rates for the key primary healthcare interventions prioritized by the Millennium Development Goals. This ratio is far from being reached in Lao PDR. In Indonesia and the Philippines this ratio seems to be easily reached, but the unequal distribution of staff in favour of the urban areas and retention problems, especially in rural areas, leads to staff shortages in some country regions. Employment of local health staff, task shifting and involvement of community health workers are strategies which might have a positive impact on this unequal distribution of health workers and on newborn health outcomes ,.Several strategies to reduce socio-economic and geographic inequities in newborn health, are known and have proven to be successful ,-.

In Indonesia, Lao PDR and the Philippines some of these were introduced, such as: free newborn care in Lao PDR, introduction of health insurance schemes in Indonesia and the Philippines, and introduction of village midwifes in Indonesia and village health stations in the Philippines. Apart from the free newborn care in Lao PDR, all the other strategies were implemented more than one decade ago. Despite the long-lasting implementation of these strategies, the inequity in newborn mortality remains high as can be seen in Table. More focus on context specific approaches is needed ,. A decentralised health system offers the opportunity to provide context specific solutions. However, several studies found that decentralisation does not always enhance the desired outcomes -. We noticed that, in all three study countries, weak leadership and limited management and strategic thinking skills at decentralised level hamper the implementation of strategies needed to increase access to quality newborn care for the most vulnerable.

Limitations of this studyThe study has several important limitations. First, because this study was a short term consultancy assignment time and resource constraints made it impossible to conduct an in-depth analysis of the complexities of newborn care. However, we tried to be as comprehensive as possible by covering all health system building blocks and their specificities for newborn care. Secondly, due to the study set-up, audio-recording and full transcription of interviews was not possible. Third, because of time constraints the field visits included only a few districts and health facilities in each study country. The newborn healthcare situation might be different in other districts. Fourth, because participation at interviews was voluntary, it might have resulted in selection bias.

Fifth, because only available data on newborn care was used for the situation analysis, not all aspects of newborn care could be assessed thoroughly by lack of data. ConclusionIn Indonesia, Lao PDR and the Philippines we identified the need and opportunity to improve access to good quality newborn care. There is an urgent need to address weak leadership and governance regarding newborn care, the quality of newborn care provided and inequities in newborn care. Only then can newborn mortality and morbidity decrease in these three countries. Child survival programmes focussed on children over four weeks of age have shown to have positive outcomes. Similar efforts as those used in these programmes should be considered in newborn care.

Authors’ contributionsEls Duysburgh was the overall study coordinator and end responsible and developed together with Birgit Kerstens the study design and study tools. She coordinated the newborn care needs assessment in Indonesia and as such participated in data collection (document review, key informant interviews and health facility visits), data interpretation and report writing in Indonesia. She coordinated the writing of this paper. Birgit Kerstens developed together with Els Duysburgh the study design and study tools.

She coordinated the newborn care needs assessment in Lao PDR and as such participated in data collection (document review, key informant interviews and health facility visits), data interpretation and report writing in Lao PDR. She contributed to the writing of this paper by giving inputs on the general context of the paper. Melissa Diaz coordinated the newborn care assessment in the Philippines and as such participated in data collection (document review, key informant interviews and health facility visits), data interpretation and report writing in the Philippines. She contributed to the writing of this paper by giving inputs on the general context of the paper.

Vini Fardhdiani participated in data collection (document review, key informant interviews and health facility visits), data interpretation and report writing in Indonesia. She contributed to the writing of this paper by giving inputs and checking statements regarding newborn care in Indonesia. Katherine Ann V.

Reyes participated in data collection (document review, key informant interviews and health facility visits), data interpretation and report writing in the Philippines. She contributed to the writing of this paper by giving inputs and checking statements regarding newborn care in the Philippines. Khamphong Phommachanh participated in data collection (document review, key informant interviews and health facility visits), data interpretation and report writing in Lao PDR. She contributed to the writing of this paper by giving inputs and checking statements regarding newborn care in Lao PDR. Marleen Temmerman gave inputs to and supported the paper writing and reviewed the final draft. Basil Rodriques participated in the selection of the study countries.

He gave inputs to the different country reports written as part of the study and he gave inputs to this paper. Nabila Zaka conceptualized and supervised the study for UNICEF East Asia and Pacific Regional Office.

She coordinated the initiation and implementation of the study with UNICEF country focal points and facilitated the government approval process in the study countries. She gave inputs to the study design and study tools. She gave comments and inputs on data interpretation and gave inputs to the country reports written as part of the study.

She contributed to the writing of this paper by giving inputs on the general context of the paper. All authors read and approved the final manuscript.

On 8 November 2013, supertyphoon Haiyan made landfall in the Philippines, severely disrupting health service delivery. Reestablishment of essential services for birthing mothers and their newborns became high priority.

Following a baseline assessment, an Essential Intrapartum and Newborn Care (EINC) training package was implemented and posttraining assessments (1 and 3 months after training) were undertaken. Baseline assessments ( n = 56 facilities) revealed gaps in provider's skill and shortage of life-saving commodities. Facilities lacked newborn bags/masks (9%), towels (6%), and magnesium sulfate (39%). Service providers lacked skills in partograph use (54%), antenatal steroid (44%) use, and breastfeeding initiation (50%). At 3 months after training ( n = 51 facilities), dramatic increases in correct partograph use (to 92%), antenatal steroid use (to 98%), breastfeeding initiation (to 86%), kangaroo mother care (to 94%), availability of magnesium sulfate (to 94%), and bag/masks (to 88%) were documented. Gaps persisted for skills in assisted vaginal delivery and removal of placental fragments.

Health services were severely disrupted after supertyphoon Haiyan. Our study demonstrates that essential birthing services and quality improvements to strengthen local health systems can be restored in a timely manner even in immediate postdisaster settings. IntroductionSupertyphoon Haiyan made landfall in the Philippines on November 8, 2013, with most of the damages sustained in the central part of the country.

14.1 million people were affected, mostly in Eastern Visayas (Region 8), followed by Central Visayas (Region 7) and Western Visayas (Region 6). Immediate response efforts for vast areas ravaged by Haiyan were extremely difficult, due to breakdown of transportation and communication infrastructure, and consisted largely of provision of food and water, infant and child feeding, and triage and treatment for traumatic injuries and acute medical illnesses ,. Demand for health services surged as complete devastation of health infrastructure, logistics, and human resources rendered the local health system unable to respond. National and local government and interagency assessments immediately after the typhoon identified the reestablishment of health services for mothers and children, particularly primary and secondary care for obstetric emergencies, as a priority. The Emergency Health Cluster led by the Department of Health (DOH) (co-led by the World Health Organization, WHO) provided recommendations and supported appropriate humanitarian responses. Among the WHO endorsed interventions for saving the lives of mothers and children is the so-called Essential Intrapartum and Newborn Care (EINC), a package of cost-effective time-bound interventions.

In the Philippines, EINC (popularly known as “Unang Yakap” or the First Embrace) is implemented and mainstreamed in practice protocols or tools following quality improvement principles. The development of this standardized protocol was triggered by data from observational assessments in 51 government hospitals in the Philippines revealing that practices in the immediate newborn care period were undermining thermoregulation and breastfeeding initiation of newborns. The importance of providing quality care for women during labor and delivery and implementation of safe practices for their newborns to ensure their best outcomes became paramount.

Prior to typhoon Haiyan, implementation of the EINC Protocol was being undertaken only in selected government hospitals and primary level facilities (rural health units and district hospitals). Inequity and system barriers to bring implementation to scale persisted despite national health policies being in place. Neonatal mortality rate (NMR) reported in the National Demographic and Health Survey (NDHS 2013) was 13 per 1000 live births nationally and 15, 18, and 10 per 1000 live births in Western, Central, and Eastern Visayas regions, respectively.When a 7.2 magnitude earthquake jolted the province of Bohol in the Visayas region one month prior to typhoon Haiyan, WHO supported the rapid building of health worker capacity for maternal/newborn care in a postdisaster setting. EINC training packages were updated to incorporate new WHO guidelines on basic newborn resuscitation and postnatal care of mothers and newborns, including magnesium sulfate administration, to address gaps in care. After a pilot implementation in Bohol province, the training modules with the expanded content were endorsed by WHO for utilization in postdisaster areas where similar needs existed.The aim of this intervention was to support the reestablishment of health care services for birthing mothers and their newborns in the areas affected by typhoon Haiyan guided by quality improvement principles. Specific objectives were to.conduct EINC training of trainers (TOT) and quality assurance (QA) workshops in target areas within Eastern, Central, and Western Visayas regions to address gaps identified in the baseline assessment.and undertake rapid assessments of EINC services using a standard tool at baseline and at 1 and 3 months after the training. Flow of assessments and interventions.Using the “Newborn Services Rapid Health Facility Assessment” tool that was developed by the Interagency Newborn Indicators Technical Working Group as a template , rapid facility assessments were done at baseline (before training) and at one month and three months after training.

Technical experts acting as external assessors used the identical tool to conduct pre- and posttraining assessments during facility visits. External assessors performed ocular surveys of the access and quality of the labor-delivery and postpartum environments, equipment, supplies, and patient pathways. Information was collected through interviews of health workers and mothers, supplemented by review of records. Whenever possible, deliveries were observed.In the priority municipalities, primary level health facilities with the highest number of deliveries were intentionally selected. Based on usual patient traffic, the biggest district hospital or rural health unit (RHU) and its corresponding busiest lying-in clinic were selected, subject to the limited accessibility of facilities after typhoon Haiyan. In consideration of service delivery networks and referral flows within and across municipalities, assessments covered additional municipalities beyond the 40 priority areas.The tool was used to assess facility-based delivery and newborn care service capacity in primary and referral level facilities.

Gaps in newborn care health services were systematically identified using tracer indicators. Findings were utilized to describe capacity to address three main causes of newborn deaths: asphyxia, prematurity, and infection. Determinants were classified as (a) service availability, (b) equipment and supplies, and (c) service standards. EINC Training of TrainersUpdated EINC training modules contained brief didactic sessions on basic topics: Essential Intrapartum and Newborn Care, breastfeeding support, kangaroo mother care, Infant and Young Child Feeding in Emergencies (IYCF-E), partograph use, and the recent WHO recommendations on basic newborn resuscitation, correct administration of magnesium sulfate, and postnatal care of mothers and newborns.

Skills sessions consisted of “coaching sessions” with demonstration/return demonstrations using manikins and delivery kits. Workshops culminated with action planning sessions on effective mainstreaming of EINC in their practice.

Newborn Resuscitation Steps

These planning sessions allowed the participants to voice out their concerns and their apprehensions and discuss among themselves ways to contextualize these challenges and address them.Training of trainers (TOT) workshops were conducted in the three regions. Selection of trainees was strategic to include senior health care workers with aptitude to become trainers in their respective service delivery networks (roughly corresponding to geopolitical Interlocal Health Zones or ILHZs). Representation of involved ILHZs was ensured as much as possible to create a pool of trainers to cascade the training locally. Local trainers were further chosen from this pool based on their performance during the TOT. Participants included thirty (30) trainees each from Leyte, Eastern and Western Samar, Capiz, Iloilo, and Cebu. Cascade EINC Quality Assurance WorkshopsThe technical experts supervised and mentored the new local trainers as they implemented their own cascade quality assurance (QA) workshops.

In each of the areas, two QA workshops of 30 participants each were conducted, targeting a total of 300 capacitated skilled birth attendants. QA workshop modules for service providers were delivered over 6 half-day sessions. Pre- to postworkshop acquisition of knowledge was measured through 15 item multiple choice question written quizzes and acquisition of skills in the classroom assessments through performance checklists.

Progress in EINC implementation and quality improvement from baseline assessments through 1- and 3-month posttraining assessments.Baseline rapid assessments were done at 16 weeks after landfall in Eastern Visayas (Leyte and Eastern and Western Samar), 20 weeks after landfall in Western Visayas (Iloilo and Capiz), and 22 weeks after landfall in Central Visayas (Cebu). A total of 56 health facilities were assessed at baseline. Assessments revealed significant disruption in obstetric and newborn health services in Eastern Visayas and much less significant disruption in Central and Western Visayas.At baseline, health facilities assessed ranged from rural health units (RHU; 39), first level referral hospitals (15 community, district, and city hospitals), and, in addition, 2 provincial hospitals with birthing services. After typhoon Haiyan, the physical devastation in Eastern Visayas caused the most serious interruptions in EINC delivery. Immediate response services were provided primarily through contributions from international partners in tents and makeshift facilities.

The lack of availability of 24/7 delivery services revealed the importance of improved referral mechanisms that could bring mothers experiencing complications during or after birth to a higher level facility, if needed. These findings differed from the assessment of Central and Western Visayas municipalities, where facilities mostly sustained partial damage with no interruption of birthing services.Apart from damage to infrastructure, commodities were in serious shortage or absent with stock-outs of life-saving drugs (e.g., oxytocin, magnesium sulfate, and dexamethasone). Health human resources suffered serious setbacks not only due to substantial loss of lives among health care providers but also due to lack of training and technical capacity (in basic newborn resuscitation, care of the low birth weight, kangaroo mother care, breastfeeding, and Infant and Young Child Feeding in Emergencies (IYCF-E)). In facilities where health workers had participated in a previous 11-day Basic Emergency Obstetric and Newborn Care (BEmONC) training, low self-efficacy ratings especially in partograph use, magnesium sulfate administration, and newborn resuscitation rates were noted. Very few facilities experienced supervisory visits in the previous 6 months. None performed routine postnatal care services.

Documentation of practices was weak. Finally, not all facilities conducted regular maternal and newborn death reviews. EINC Training of Trainers (TOT)Out of 150 candidate trainers who were invited, 112 (75%) attended the training. These were maternal and child health workers holding strategic positions (provincial level program managers, hospital specialists, municipal health officers, public health nurses, and midwife supervisors). A total of five (5) training of trainer (TOT) workshops of 3 days' duration each, were conducted, one each for the provinces of Leyte, Eastern and Western Samar, Iloilo, Capiz and Cebu. Cascade EINC QA WorkshopsAs part of the training requirement, each TOT candidate trainer participated in at least one of a total of ten (10) cascade QA workshops for their colleagues, with supportive supervision and technical oversight from expert trainers.

A total of 281 out of 300 targeted skilled birth attendants (93.7%) were further trained.Thus, a total of 393 health workers completed EINC workshops over this period. 281 completed their participation in 3-day QA workshops and 112 attended the five TOT workshops. Consistent improvements in posttraining assessment quizzes and performance checklists for both the TOT and QA workshop participants were noted. Posttraining Assessments At 1 month and 3 months after training, field visits to 58 and 51 facilities, respectively, were carried out.

The facilities that completed the 3 assessments were thirty-five (35) rural health units (RHUs), 15 primary level hospitals (13 district, 1 city, and 1 community hospitals) and one (1) provincial hospital. These field visits revealed that uptake of EINC knowledge and skills was translated to significant changes in daily practice. Proportion of facilities assessed providing various services at pretraining (baseline) and at 1 and 3 months posttraining assessment (PTA), Eastern, Western, and Central Visayas post-Haiyan.In Eastern Visayas, the worst hit region, baseline assessment revealed that 27 of 36 facilities were providing birthing services. At 1 month after training, 32 of 38 assessed birthing facilities were providing round-the-clock/daily (24/7) skilled birth attendance (SBA). At 3 months, 30 of 31 birthing facilities were providing 24/7 SBA. In Western Visayas, 16 of 16 facilities were able to sustain delivery services at baseline and 1 month assessments.

One facility suspended its delivery services to undergo renovations at the 3-month assessment. All of the 15 other facilities were providing 24/7 SBA. In Central Visayas, all 4 facilities assessed were providing 24/7 SBA at baseline, 1-month, and 3-month assessments. Over the period from baseline assessment to 3 months after training, there were significant improvements in self-reported availability of services such as neonatal resuscitation, kangaroo mother care, administration of parenteral oxytocin, antibiotics, antenatal steroids, and magnesium sulfate. In contrast, persistent gaps remained for assisted vaginal delivery, manual placental removal, and manual removal of retained products after delivery. In Figures–, the proportion of facilities (%) at end line (3 months after training) is labeled. Equipment and Supplies Over the period from baseline assessment to 3 months after training (20-week, 19-week, and 14-week periods for Eastern, Western, and Central Visayas, resp.), there were significant improvements in availability of life-saving drugs (i.e., oxytocin) and equipment (i.e., for resuscitation) most notably for Eastern and Central Visayas.

For Western Visayas, some improvements were seen in the facilities but the limited availability of equipment constrained the appropriate delivery of services. Not all life-saving drugs were available in all facilities, especially antibiotics and steroids.Though there was significant improvement, persistent gaps remained for antenatal steroids, injectable gentamicin, and magnesium sulfate supplies. Towels for drying were still being provided by families instead of by facilities.

Nevirapine for prevention of mother-to-child transmission of HIV remained unavailable across all regions. Multidose BCG vaccines were available but considered “insufficient” by health workers. Many facilities had moved their weighing scales from their delivery areas to their maternity care areas for deferred weighing until after the first breastfeed, as recommended in EINC protocols.

Protocols for IMPAC, sick newborn care/referral, preterm labor management, and CEmONC manuals remain unavailable. Service Standards In addition to parameters included in the Newborn Care Services Rapid Assessment Tool, selected parameters relevant to the Philippines EINC Protocol and Basic Emergency Obstetric and Newborn Care (BEmONC) services standards were assessed through interviews of health service providers.Significant improvements in service standards using tracer indicators were noted across all regions over the period from pretraining assessment to the 3 months posttraining assessment. ConclusionsThis intervention filled the service gaps identified immediately after a large scale natural disaster and helped to reestablish and improve the delivery of health services in affected areas.

Where baseline indices were worse because of the immediate effects of the typhoon (i.e., Eastern Visayas), the magnitude of improvement across most assessed parameters was more significant. However, there were other parameters where gaps persist despite intensive efforts and other methods and systemic interventions need to be explored address these deficiencies.Our study demonstrates that quick important quality improvements can be made in a timely manner across a range of health facilities and with differing cadres of health workers, even in immediate postdisaster settings.

Capacity building of health workers and strengthening of the local health system to deliver quality care before, during, and in the aftermath of a major disaster are among the preconditions for a resilient health system. Building the evidence base linking these quality improvement efforts in EINC and basic newborn resuscitation with impact on newborn and maternal health outcomes postdisaster is imperative.