Essential Newborn Care: The Evidence, The State of Practice and The ResponsePractice and The Response

Mariella Sugue Castillo, MD, MScTechnical Officer, Maternal & Child Health

Office of the WHO Representative in the Philippines

4 March 2010

• Are we going to meet MDG 4?

• What Newborn Care Practices will save lives?

OUTLINE

• The Current State of Newborn Care Practices

• Guideline Development Process for The Essential Newborn Care Protocol

• <5 Yr Old mortality decreased 40% (1988-1998)

• Past 10 years, declined by 20%

• Slow decline since neonatal mortality hasn’t improv ed

60

70

80Under Five Mortality Rate

<5 year old and Neonatal Mortality, 1988 to 2008

0

10

20

30

40

50

60

1988 1993 1998 2003 2008

Neonatal MR

DHS 88, 93, 98, 03, 08

82,000 Filipino children die annually, most could have been prevented

Source: CHERG estimates of under-five deaths, 2000-03

The Philippines is one of the 42 countries that account for 90% of global under-five mortality

Majority of newborns die due to stressful events or conditions during labor, delivery and the immediate

postpartum period.

3 out of 4 newborn deaths occur in the week of life

Num

ber

of dea

ths

Day of Life

Num

ber

of dea

ths

NDHS 2003, special tabulations

Neonatal Mortality is high for Rich and Poor, NDHS 2003

15

20

25

0

5

10

Poorest 2nd 3rd 4th Richest

Is newborn sepsis a problem limited to Ospital ng Makati?

Nationwide home deliveries by non-health professionals

Nationwide Hospitals

P-value

Newborn Sepsis §

Not Studied 6%

Newborn deaths *

16.8/1000 Live Births

16.0/1000 Live Births

0.82

§ Sobel, Silvestre, Mantaring 2009* Sobel, Oliveros, Nyunt-U 2009

What Immediate Newborn Care Immediate Newborn Care Practices will save lives?

Position of Delivery

Lying flat on back during second stage of labor is best:

• True• True

• False

Position of Delivery

Lying flat on back during second stage of labor is best:

• True• True

• False

Delivery Position of Choice: The Evidence

• Reduced duration of 1 st and 2nd stage of labor – 1st stage: MD 0.99 hrs (95% CI 1.60 to 0.39)– 2nd stage: MD 4.28 mins (95% CI 2.93 - 5.63)

Office of the WHO Representative in the Philippines

– 2 stage: MD 4.28 mins (95% CI 2.93 - 5.63)

• Reduction in assisted deliveries– RR 0.80, (95% CI 0.69 - 0.92)

Lawrence A, et al. Maternal positions and mobility during first stage labour. Cochrane Database of Systematic Reviews: Reviews 2009 Issue 2 John Wiley & Sons, Ltd Chichester, UK.

Gupta JK, Hofmeyr GJ, Smyth R. Position in the second stage of labour for women without epidural anaesthesia. Cochrane Database of Systematic Reviews 2004, Issue 1.

Antenatal Steroids: The Evidence• Overall reduction in neonatal death

– RR 0.69 (95% CI 0.58 - 0.81)

• Reduction in RDS– RR 0.66, (95% CI 0.59 to 0.73),

• Reduction in cerebroventricular hemorrhage

Office of the WHO Representative in the Philippines

• Reduction in cerebroventricular hemorrhage– RR 0.54 (95% CI 0.43 to 0.69)

• Reduction in sepsis in the first 48 hours of life – RR 0.56 (95% CI0.38 to 0.85)

Roberts D, Dalziel SR. Cochrane Database of Systematic Reviews 2006, Issue 3.

Does not increase risk of death, chorioamnionitis o r puerperal sepsis in the mother

After a baby is born, what should be the first action performed?

A. Clamp and cut the cord

B. Dry the baby

C. Suction the baby’s mouth and nose

D. Do foot printing

After a baby is born, what should be the first action performed?

A. Clamp and cut the cord

B. Dry the baby

C. Suction the baby’s mouth and nose

D. Do foot printing

Described more below

Immediate Thorough Drying

• Immediate drying – Stimulates breathing– Prevents hypothermia

• Hypothermia which can lead to

Tunell R., in Improving Newborn Health in Developing Countries, A. Costello and D. Manandhar, Editors. 2000, Imperial College Press: London, UK. p. 207-220; Tollin M, et al.. Cell Mol Life Sci 2005

• Hypothermia which can lead to – Infection– Coagulation defects– Acidosis– Delayed fetal to newborn circulatory adjustment– Hyaline membrane disease– Brain hemorrhage

During drying and stimulation of the baby, your rapid assessment shows that the baby is

crying. What is your next action?

A. Suction the baby’s mouth and nose

B. Clamp and cut the cord

C. Do skin-to-skin contact

D. Do early latching on

During drying and stimulation of the baby, your rapid assessment shows that the baby is

crying. What is your next action?

A. Suction the baby’s mouth and noseA. Suction the baby’s mouth and nose

B. Clamp and cut the cord

C. Do skin-to-skin contact

D. Do early latching on

What are the benefits of immediate skin-to-skin contact?

A. Provides warmth

B. Increases overall duration of exclusive B. Increases overall duration of exclusive breastfeeding

C. Allows colonization with good bacteria

D. All of the above

What are the benefits of immediate skin-to-skin contact (SSC)?

A. Provides warmth

B. Increases overall duration of exclusive B. Increases overall duration of exclusive breastfeeding

C. Allows colonization with good bacteria

D. All of the above

Skin-to-Skin Contact• Generally perceived to be an intervention for

provision of warmth and bonding

• Less well appreciated are its contributions to – Overall success of breastfeeding/colostrum

feedingfeeding– Stimulation of the mucosa-associated

lymphoid tissue system – Protection from hypoglycemia– Colonization with maternal skin flora

Moore E, et al. Cochrane Rev. 2007 Jul 18;(3). Anderson GC, et al. Cochrane Rev 2003;(2).Brandtzaeg P. Ann N Y Acad Sci 2002;964:13–45

When should the cord be clamped after birth?

A. When the cord pulsations stopA. When the cord pulsations stop

B. Between 1 and 3 minutes

C. Between 30 secs - 1 minute in preterms

D. All of the above are appropriate

When should the cord be clamped after birth?

A. When the cord pulsations stopA. When the cord pulsations stop

B. Between 1 and 3 minutes

C. Between 30 secs - 1 minute in preterms

D. All of the above are appropriate

Properly-Timed cord clamping

• Term babies: less anemia in the newborn24-48 hrs after birth – RR 0.2 (95% CI 0.06, 0.6)– NNT 7, (4.5- 20.8)

• Preterms: less infant anemia– RR 0.49 (95% CI 0.3, 0.81) 1) Ceriani Cernadas – RR 0.49 (95% CI 0.3, 0.81)– NNT 3 (1.6 - 29.6)

• Preterms: less intraventricular hemorrhage– RR 0.59 (95% CI 0.35, 0.92)– NNT 2 (1.4 - 9.8)

• No significant impact on incidence of Post-Partum Hemorrhage

1) Ceriani Cernadas ,et al. 2006;

2) Rabe H, et al. 2004;

3) McDonald SJ, et al. 2008;

4) Hutton EK, et al. 2007;

5) Kugelman A, et al. 2007

6) Van Rheenen PF, et al. 2006

7) Van Rheenen PF & Brabin BJ. 2006

Washing the Baby in the First 6 Hours is Protective:

• True

• False

Washing the Baby in the First 6 Hours is Protective:

• True

• False

• Hypothermia which can lead to – infection, coagulation defects, acidosis, delayed f etal to

newborn circulatory adjustment, hyaline membrane disease, brain hemorrhage

• Infection

Early Washing Can Lead to:

• Infection– The vernix is a protective barrier to bacteria such as E.

coli and Group B Strep; so is maternal bacterial colonization

• No crawling reflex.

Tunell R., Cell Mol Life Sci 2005; 62:2390-99; Righard L, Alade M. Lancet 1990; 336: 1105-07.

Non-separation of Newborn from Mother for Early

Breastfeeding

• Weighing, bathing, eye care, examinations, injections should be done after the first full injections should be done after the first full breastfeed is completed

• Postpone washing until at least 6 hours

Delaying Initiation of breastfeeding increases risk of infection-related death,

Nepal 2008, 22,838 breastfed babies

8

10

12

14

RR

Mullany LC, et al. J Nutr, 2008; 138(3):599-603.

0

2

4

6

8

<1 1-24 24-48 48-72 >72

Hours after Birth

Ghana, Cohort Study, 10,947 breastfed infants, 2003-2004

Delaying Initiation of breastfeeding increases risk of infection-related death,

Ghana 2004, 10,947 breastfed infants

The evidence is solid:

The following Newborn Care Practices will save lives:

Immediate and Thorough Drying

Early Skin-to-Skin Contact

Properly Timed Cord Clamping

Non-separation of Newborn from Mother for Early Breastfeeding

Current State of Newborn Care Practices Newborn Care Practices in Philippine Hospitals

Obstetric practices in Philippine Hospitals need to realign with

the evidence-base: an observational study

Action % WHO Standard

Oxytocin 24.8% 100%

Antibiotic given 78.8% Only if indicated

Indication recorded in chart 10.4% 100% of those given

antibioticsantibiotics

Antenatal steroids in PTL 23% 100%

Position of choice 0 100%

Maternal support 0.8% 100%

Partograph used 3.5% 100%

Cesarean section 22.2% Only if indicated

Indication for CS recorded in chart 37.4% 100% of CS

Mantaring, Sobel, Silvestre, Catibog, 2009

Intervention Percentage and

Median Time

WHO Standard

Cord Clamp 12 sec

99% in < 1 min

Until pulsations stop

(1-3 mins)

Drying 97% at 1 min 100% Immediately

Immediate Skin-to-skin 9.6% at 5 min >90% (except those

A Minute-by-Minute Assessment of Newborn Care within the First Hour of Life in Philippines Hospit als (2009)

Immediate Skin-to-skin

contact

9.6% at 5 min >90% (except those

needing resuscitation)

Put on cold surface 12% None

Not dried 2.5% None

Head not dried 6.2% None

Wash 84% at 8 min >6 hours

Temp taken before 17% AllSobel, Silvestre, Mantaring, Oliveros, 2009

Intervention Median Time or

Percentage

WHO Standard

Breast feed 69.3% at 10 min Within 1 hour (but

when baby shows

signs)

Separated from 92.9% at 12 min >1 hour

A Minute-by-Minute Assessment of Newborn Care within the First Hour of Life in Philippines Hospit als (2009)

Separated from

mother

92.9% at 12 min >1 hour

Weigh 100% at 13 min > 1 hour

Exam 75.7% at 17 min > 1 hour

Hepatitis B Vaccine 69.4% at 20 min >1 hour

Nursery 52% at 19 min Never

Rooming in 83% (155 min) Immediately with mother

Sobel, Silvestre, Mantaring, Oliveros, 2009

Resuscitation action of 26 infants with apnea:

Action N (%)

Suctioning 24 (92.3%)

Bag and Mask 12 (46.1%) at 120 seconds

Slapping back 7 (26.9%)

Intubation 2 (7.7%) at 3 and 6 min

Chest compressions/ Epi 2 (7.7%) at 4 min

Drying *** 1 (3.8%)

*** Should be first action, immediately, for full 30 seconds, unless both floppy/limp and apneic Sobel, Silvestre, Mantaring, Oliveros, 2009

Unnecessary Resuscitation

• Of the 455 who were already breathing– 94.9% suctioned once– 84.0% suctioned more than once– 84.0% suctioned more than once

Sobel, Silvestre, Mantaring, Oliveros, 2009

Differences in Practices

• There was minimal difference in timing or performance of immediate newborn interventions regardless of newborn interventions regardless of whether the attendant at delivery was a pediatrician, nurse or midwife

Sobel, Silvestre, Mantaring, Oliveros, 2009

Variation in Sequence of Interventions

Sobel, Silvestre, Mantaring, Oliveros, 2009

Indications that a guideline is needed:

• Wide variation in practices• Reports of inappropriate care• High health care costs• High health care costs

All of these indicate the Essential Newborn Care Protocol is needed in the Philippines.

Essential Newborn Care Protocol was developed to developed to address these

issues

Guideline Development Process

• Convened Technical Committee

• Identified problems in newborn care incl. observational studies– Appraised evidence for

effective interventions incl. effective interventions incl. WHO Guidelines

– GRADE methodology– Evidence-based draft

developed• Individual and en banc panel

stakeholder and expert review• Protocol finalized• Administrative Order issued

Next Steps

• Dissemination• Implementation• Monitoring• Monitoring

Improving Philippine Health Delivery Service to Save Mothers and Babies by

Dr. Howard Sobel

• PPS 47th Annual Convention Plenary SessionSession

• April 19, 2010

• 9:30 – 10:30 am

• PICC Plenary Hall

CLOSING THOUGHTS• The current state of newborn care needs urgent

action– Evidence-based interventions are not practiced

sufficiently.– ENC Protocol provides an evidence-based, low

cost, low technology package of interventions that cost, low technology package of interventions that will save tens of thousands of lives.

• Each of us, as individuals and as organizations, have to look inward to find ways to implement ENC

• Join us to bring Unang Yakap to your membership and every person they can influence.