1

Chapter 1
Introduction

The general field of interest of the study is EINC (Essential Intrapartum and Newborn
Care) practices. The EINC practices are evidenced-based standards for safe and quality care of
birthing mothers and their newborns, within the 48 hours of Intrapartum period (labor and
delivery) and a week of life for the newborn. Developed and field tested by international and
local experts, EINC practices reflect current knowledge. EINC distinguishes the necessary
practices in the delivery and care for the newborn and the mother, from the unnecessary. In this
study, the researchers shall be able to know the EINC practices implemented by selected lying-in
centers its effectiveness and how they differ from each other.

Background of the Study

Often in the Philippines, mothers give birth to children who do not live to see the next
day. In 2011, more than 10,000 Filipino babies died on the day they were born. The high number
of first day deaths illustrates the need to make newborn care a top health priority. According to
studies preterm birth is the worlds largest killer of babies, causing more than 1 million deaths
each year worldwide, yet 75 per cent could be saved without high technology care. The
Philippines ranks 8th out of 184 countries for the number of babies born prematurely, and ranks
17th for the total number of deaths due to complications from preterm birth. Back then in 2011 in
the Philippines 48% of children who die under the age of 5 years are newborns, and 39% of these
die from preterm complications, making this the leading cause of newborn mortality.

Philippines is one of 42 countries that account for 90% of worldwide deaths in children
under age 5. According to WHO statistics from 2011, 25 of every 1000 Filipino children are
likely to die by age 5. Half of these children are neonates (infants 0-28 days of age). In 2011,
there were approximately 2,358,000 live births in the country. This translates to over 28,000
newborn deaths in one year alone.

While 12 newborn deaths per 1000 live births is an

improvement from 22 per 1000 in 1990, the rate has not decreased significantly in the last 6
years. To compare, the neonatal mortality rate (NMR) in the United States is 4 per 1000 as of
2011. In Japan, it is 1 per 1000. Prematurity, asphyxia and infection together cause over 60% of
neonatal deaths, and 75% of deaths occur within the first 7 days of life, with the vast majority
dying within the first 48 hours. Because of this, the Unang Yakap protocol addresses the first 7
days of life, focusing on the time immediately surrounding birth. In the Philippines, health care is
more accessible to those who can afford it. As such, one might assume that the majority of
newborn deaths occur among the poorest in the country. While it is true that the rates are higher
among the poor (20 per 1000), even among the richest quintile of our population, the NMR is
unacceptably high at 10 per 1000 live birth. One of the initiatives that the Department of Health
(DOH) and the World Health Organization (WHO) to improve neonatal conditions is the
introduction of the Essential Intrapartum and Newborn Care (EINC) to save mothers and
newborns. Dubbed as Unang Yakap (First Embrace) 4 and 5, the set of practices aims to
provide the highest standard for safe and quality care for birthing mothers and healthy newborns
in the first 48 hours and up to a week of life of the newborn.
The logical conclusion is that the problem is system-wide and may not be solely financial
in origin. A study by Drs. Sobel, Silvestre, Mantaring, Oliveros and Nyunt-U published in 2011
evaluated the minute-to-minute newborn care performed in 51 large hospitals in the Philippines.
The data they obtained allowed them to identify and address steps in early newborn care that
were likely contributing to neonatal infection and death.

This resulted in the creation of the

Essential Intrapartum and Newborn Care Protocol, more commonly known as Unang Yakap.
The hope is to provide a standard of care for mothers and newborns at the time of birth
regardless of where they deliver, be it a birthing center, a primary care hospital or a large referral
center.

The Unang Yakap program, meaning First Embrace, is a campaign of the Philippines
Department of Health (DOH), in cooperation with the World Health Organization (WHO), to
adopt the Essential Intrapartum and Newborn Care (EINC) guidelines for the safe and quality
care of mothers and their newborns. It stresses the importance of delayed bathing and thorough
drying of a newborn, early skin-to-skin contact with the mother, early and exclusive
breastfeeding, and properly timed cord clamping. With over 60% of births in the Philippines now
being attended by a skilled health worker, implementing the EINC protocol ensures that quality
and timely care is provided by all skilled birth attendants, so that all mothers and newborns
receive the best possible care during pregnancy and childbirth.
To achieve that end, the Philippines is in the process of developing clinical guidelines and
standards for addressing the leading causes of neonatal mortality, and will work with health
professionals (midwives, nurses, social workers, physicians) other key stakeholders and partners
including community-based health and nutrition workers and local government units (LGUs) to
ensure all the relevant cadres of health service providers in the country are equipped with the
right knowledge, attitudes and skills to save more newborn lives. In August of 2013, the DOH
hosted experts from local and international groups including UNICEF and WHO to focus on
ways to improve newborn and maternal health by identifying the remaining barriers standing in
the way of our goals. The national consultation was part of a global effort to develop Every
Newborn, an action plan to save newborn lives.
What is crucial for preterm babies is that they receive appropriate newborn care, said
Dr Mariella Castillo, UNICEFs Mother and Child Health specialist. This means ensuring that
babies who have difficulty breathing get quick attention, and that all newborns are breastfed and
kept warm, dry and clean.

Objective of the Study

This study seeks to evaluate the implementation of Essential Intrapartum and Newborn
Care practices in two selected lying-in centers in Zamboanga City. Specifically, it aims to
evaluate on the following:
A. Newborn Practices:
a. Immediate and thorough drying of the newborn
b. Early skin-to-skin contact
c. Properly-timed cord clamping
d. Initiation of breastfeeding
B. Newborn Interventions:
a. Routine suctioning
b. Footprinting
c. Early bathing and washings
d. Routine separation
e. Giving glucose water or artificial milk substances
C. Intrapartum Care:
a. Continuous support during childbirth
b. Mobility during labor
c. Pain relief in labor
d. Pantograph use to monitor progress of labor
e. Spontaneous flushing in semi-upright position
f. Hand hygiene
g. Active management of the third stage of labor
h. Antenatal steroids in preterm labor

D. Intrapartum Interventions:
a. Enema
b. Shaving
c. Restricted intake of food and fluids
d. Routine intravenous infusion
e. Fundal pressure
f. Early amniotomy and oxytocin augmentation
g. Routine episiotomy
Significance of the Study

The research of the study is for the benefits of the incoming newborns who will be
receiving the EINC practices which will probably reduce their morbidity rate. The researchers
will identify the factors that affect newborn morbidity regarding the EINC practices. The result
of this study will help future birthing mothers to avoid complications on their newborns. This
increases the support of the practitioners and health facilities on contributing wholesomeness to
the mother and her newborn. And for all of these to become successful, it is anticipated that the
protocols of EINC will be more precisely implemented.
Scope and Delimitation

The coverage of the study will be two lying-in centers and its health workers such as the
PHN, PHM target respondents along with the postpartum mothers that gave birth between the
months of June to August 2016. Factors which may restrain the researchers study are time and
money considering only two lying-in centers. One unit near the city proper and another one more
distant. These units are Canelar Health Center and Guiwan Health Center. The researchers study
will start by gaining access to the units probably on June 2016, and will last only for a month or
more if necessary.

Chapter 2
Literature Review

The researchers have chosen to place their efforts in this study about the application of
Essential Intrapartum and Newborn Care (EINC) on some of the lying-in centers within the
range of their research because it is the management of premature and low birth weight
newborns, which alone accounts for 40% of newborn deaths in the Philippines. Maternal death is
one of the rising health issues in the Philippines. It is alarming to know that at often times,
mothers give birth to children who may not live to see the next day. Statistics shows that
intrapartum period and third stage of labor are the very crucial periods for the expectant mother,
as well as the first six hours of life for the newborn. To address the issue, The Essential
Intrapartum and Newborn Care (EINC) were developed. Through this, Obstetric Delivery Room
(OB-DR) Nurses shall be updated with the evidence-based maternal and newborn care to ensure
patient safety, thus, reducing maternal and child mortality. This study aims to describe the
compliance of lying-in centers especially on the rural areas of Zamboanga, to the EINC
Protocols. In the said literature the researchers will tackle the main reasons for the premature and
low birth weight newborns, and how EINC equipped our country with the right knowledge,
attitudes and skills to save more newborn lives and improvements that could be done.

Why did EINC Exist

A study entitled Two million intrapartum-related stillbirths and neonatal deaths: Where,
why, and what can be done? (Joy E. Lawna, 2009) says as an introduction that Intrapartumrelated neonatal deaths (birth asphyxia) are a leading cause of child mortality globally,
outnumbering deaths from malaria. Reduction is crucial to meeting the fourth Millennium

Development Goal (MDG), and is intimately linked to intrapartum stillbirths as well as maternal
health and MDG 5, yet there is a lack of consensus on what works, especially in weak health
systems. Being the objectives are to clarify terminology for intrapartum-related outcomes; to
describe the intrapartum-related global burden; to present current coverage and trends for care at
birth; and to outline aims and methods for this comprehensive 7-paper supplement reviewing
strategies to reduce intrapartum-related deaths. Which gave results in Birth is a critical time for
the mother and fetus with an estimated 1.02 million intrapartum stillbirths, 904 000 intrapartumrelated neonatal deaths, and around 42% of the 535 900 maternal deaths each year. Most of the
burden (99%) occurs in low- and middle-income countries. Intrapartum-related neonatal
mortality rates are 25-fold higher in the lowest income countries and intrapartum stillbirth rates
are up to 50-fold higher. Maternal risk factors and delays in accessing care are critical
contributors. The rural poor are at particular risk, and also have the lowest coverage of skilled
care at birth. Almost 30 000 abstracts were searched and the evidence is evaluated and reported
in the 6 subsequent papers. In which the research concluded that each year the deaths of 2
million babies are linked to complications during birth and the burden is inequitably carried by
the poor. Evidence-based strategies are urgently needed to reduce the burden of intrapartumrelated deaths particularly in low- and middle-income settings where 60 million women give
birth at home.

Benefits of EINC

According to a research study by (Mohammad Yawar Yakoob, 2011) entitled The effect
of providing skilled birth attendance and emergency obstetric care in preventing stillbirths of the
global burden of 2.6 million stillbirths, around 1.2 million occur during labour i.e. are
intrapartum deaths. In low-/middle-income countries, a significant proportion of women give
birth at home, usually in the absence of a skilled birth attendant. This review discusses the
impact of skilled birth attendance (SBA) and the provision of Emergency Obstetric Care (EOC)
on stillbirths and perinatal mortality. Using a systematic literature search and was performed on
PubMed/MEDLINE, Cochrane Database and the WHO regional libraries. Data of all eligible
studies were extracted into a standardized Excel sheet containing variables such as participants

characteristics, sample size, location, setting, blinding, allocation concealment, intervention and
control details and limitations. We undertook a meta-analysis of the impact of SBA on stillbirths.
Given the paucity of data from randomized trials or robust quasi-experimental designs, we
undertook an expert Delphi consultation to determine impact estimates of provision of Basic and
Comprehensive EOC on reducing stillbirths if there would be universal coverage (99%). The
literature search yielded 871 hits. A total of 21 studies were selected for data abstraction. Our
meta-analysis on community-based skilled birth attendance based on two before-after studies
showed a 23% significant reduction in stillbirths. The overall quality grade of available evidence
for this intervention on stillbirths was moderate. The Delphi process supported the estimated
reduction in stillbirths by skilled attendance and experts further suggested that the provision of
Basic EOC had the potential to avert intrapartum stillbirths by 45% and with provision of
Comprehensive EOC this could be reduced by 75%. These estimates are conservative, consistent
with historical trends in maternal and perinatal mortality from both developed and developing
countries, and are recommended for inclusion in the Lives Saved Tool (LiST) model. It
concluded both Skilled Birth Attendance and Emergency/or Essential Obstetric Care have the
potential to reduce the number of stillbirths seen globally. Further evidence is needed to be able
to calculate an effect size.
Another research study entitled Women's groups practising participatory learning and action to
improve maternal and newborn health in low-resource settings: a systematic review and metaanalysis by (Dr Audrey Prost P. ,., 2013) Maternal and neonatal mortality rates remain high in
many low-income and middle-income countries. Different approaches for the improvement of
birth outcomes have been used in community-based interventions, with heterogeneous effects on
survival. We assessed the effects of women's groups practising participatory learning and action,
compared with usual care, on birth outcomes in low-resource settings. We did a systematic
review and meta-analysis of randomised controlled trials undertaken in Bangladesh, India,
Malawi, and Nepal in which the effects of women's groups practising participatory learning and
action were assessed to identify population-level predictors of effect on maternal mortality,
neonatal mortality, and stillbirths. We also reviewed the cost-effectiveness of the women's group
intervention and estimated its potential effect at scale in Countdown countries. Seven trials (119
428 births) met the inclusion criteria. Meta-analyses of all trials showed that exposure to
women's groups was associated with a 23% non-significant reduction in maternal mortality, a

20% reduction in neonatal mortality, and a 7% non-significant reduction in stillbirths, with high
heterogeneity for maternal and neonatal results. In the meta-regression analyses, the proportion
of pregnant women in groups was linearly associated with reduction in both maternal and
neonatal mortality. A subgroup analysis of the four studies in which at least 30% of pregnant
women participated in groups showed a 49% reduction in maternal mortality and a 33%
reduction in neonatal mortality. The intervention was cost effective by WHO standards and could
save an estimated 283000 newborn infants and 36600 mothers per year if implemented in rural
areas of 74 Countdown countries. With the participation of at least a third of pregnant women
and adequate population coverage, women's groups practising participatory learning and action
are a cost-effective strategy to improve maternal and neonatal survival in low-resource settings.

Issues

According to a study conducted by (Joy E. Lawna b. ,., 2009) entitled Reducing

intrapartum-related deaths and disability: Can the health system deliver? states that each year
1.02 million intrapartum stillbirths and 904 000 intrapartum-related neonatal deaths (formerly
called birth asphyxia) occur, closely linked to 536 000 maternal deaths, an estimated 42% of
which are intrapartum-related. Being to summarize the results of a systematic evidence review,
and synthesize actions required to strengthen healthcare delivery systems and home care to
reduce intrapartum-related deaths as its objectives. Wherein for this series, systematic searches
were undertaken, data synthesized, and meta-analyses carried out for various aspects of
intrapartum care, including: obstetric care, neonatal resuscitation, strategies to link communities
with facility-based care, care within communities for 60 million non-facility births, and perinatal
audit. We used the Lives Saved Tool (LiST) to estimate neonatal deaths prevented with relevant
interventions under 2 scenarios: (1) to address missed opportunities for facility and home births;
and (2) assuming full coverage of comprehensive emergency obstetric care and emergency
newborn care. Countries were first grouped into 5 Categories according to level of neonatal
mortality rate and examined, and then priorities were suggested to reduce intrapartum-related
deaths for each Category based on health performance and possible lives saved. Resulting on a
moderate GRADE evidence of effectiveness for the reduction of intrapartum-related mortality

10

through facility-based neonatal resuscitation, perinatal audit, integrated community health

worker packages, and community mobilization. The quality of evidence for obstetric care is low,
requiring further evaluation for effect on perinatal outcomes, but is expected to be high impact.
Over three-quarters of intrapartum-related deaths occur in settings with weak health systems
marked by low coverage of skilled birth attendance (< 50%), low density of skilled human
resources (< 0.9 per 1000 population) and low per capita spending on health (< US $20 per year).
By providing comprehensive emergency obstetric care and emergency newborn care for births
already occurring in facilities, 327 200 intrapartum-related neonatal deaths could be averted
globally, and with full (90%) coverage, 613 000 intrapartum-related neonatal deaths could be
saved, primarily in high mortality settings. Concluding that even in high-performance settings,
there is scope to improve intrapartum care and especially reduce impairment and disability.
Addressing missed opportunities for births already occurring in facilities could avert 36% of
intrapartum-related deaths. Improved quality of care through drills and audit are promising
strategies. However, the majority of deaths occur in poorly performing health systems requiring
urgent strategic planning and investment to scale up effective care at birth, neonatal resuscitation,
and community mobilization as well as to develop, adapt, and introduce tools, technologies, and
task shifting to reach the poorest.
Another one is by (Waldemar A. Carlo, 2010) (Richard J. Derman, 2010) with a title of
Newborn-Care Training and Perinatal Mortality in Developing Countries stating that of the 3.7
million neonatal deaths and 3.3 million stillbirths each year, 98% occur in developing countries.
An evaluation of community-based interventions designed to reduce the number of these deaths
is needed. With the use of a train-the-trainer model, local instructors trained birth attendants from
rural communities in six countries (Argentina, Democratic Republic of Congo, Guatemala, India,
Pakistan, and Zambia) in the World Health Organization Essential Newborn Care course (which
focuses on routine neonatal care, resuscitation, thermoregulation, breast-feeding, kangaroo
[skin-to-skin] care, care of the small baby, and common illnesses) and (except in Argentina) in a
modified version of the American Academy of Pediatrics Neonatal Resuscitation Program
(which teaches basic resuscitation in depth). The Essential Newborn Care intervention was
assessed among 57,643 infants with the use of a before-and-after design. The Neonatal
Resuscitation Program intervention was assessed as a cluster-randomized, controlled trial
involving 62,366 infants. The primary outcome was neonatal death in the first 7 days after birth.

11

Resulting of the 7-day follow-up rate to become 99.2%. After birth attendants were trained in the
Essential Newborn Care course, there was no significant reduction from baseline in the rate of
neonatal death from all causes in the 7 days after birth (relative risk with training, 0.99; 95%
confidence interval [CI], 0.81 to 1.22) or in the rate of perinatal death; there was a significant
reduction in the rate of stillbirth (relative risk with training, 0.69; 95% CI, 0.54 to 0.88;
P=0.003). In clusters of births in which attendants had been randomly assigned to receive
training in the Neonatal Resuscitation Program, as compared with control clusters, there was no
reduction in the rates of neonatal death in the 7 days after birth, stillbirth, or perinatal death.
Concluding that the rate of neonatal death in the 7 days after birth did not decrease after the
introduction of Essential Newborn Care training of community-based birth attendants, although
the rate of stillbirths was reduced. Subsequent training in the Neonatal Resuscitation Program did
not significantly reduce the mortality rates.
A study also entitled Moving beyond essential interventions for reduction of maternal
mortality (the WHO Multicountry Survey on Maternal and Newborn Health): a cross-sectional
study by (Dr Joo Paulo Souza, 2013) states that We report the main findings of the WHO
Multicountry Survey on Maternal and Newborn Health (WHOMCS), which aimed to assess the
burden of complications related to pregnancy, the coverage of key maternal health interventions,
and use of the maternal severity index (MSI) in a global network of health facilities. In our crosssectional study, we included women attending health facilities in Africa, Asia, Latin America,
and the Middle East that dealt with at least 1000 childbirths per year and had the capacity to
provide caesarean section. We obtained data from analysis of hospital records for all women
giving birth and all women who had a severe maternal outcome (SMO; ie, maternal death or
maternal near miss). We regarded coverage of key maternal health interventions as the proportion
of the target population who received an indicated intervention (eg, the proportion of women
with eclampsia who received magnesium sulphate). We used areas under the receiver operator
characteristic curves (AUROC) with 95% CI to externally validate a previously reported MSI as
an indicator of severity. We assessed the overall performance of care (ie, the ability to produce a
positive effect on health outcomes) through standardised mortality ratios. Giving results stating
that from May 1, 2010, to Dec 31, 2011, we included 314623 women attending 357 health
facilities in 29 countries (2538 had a maternal near miss and 486 maternal deaths occurred). The
mean period of data collection in each health facility was 89 days (SD 21). 23 015 (73%)

12

women had potentially life-threatening disorders and 3024 (10%) developed an SMO. 808
(267%) women with an SMO had post-partum haemorrhage and 784 (259%) had pre-eclampsia
or eclampsia. Cardiovascular, respiratory, and coagulation dysfunctions were the most frequent
organ dysfunctions in women who had an SMO. Reported mortality in countries with a high or
very high maternal mortality ratio was two-to-three-times higher than that expected for the
assessed severity despite a high coverage of essential interventions. The MSI had good accuracy
for maternal death prediction in women with markers of organ dysfunction (AUROC 0826 [95%
CI 08020851]). Interpreting that high coverage of essential interventions did not imply
reduced maternal mortality in the health-care facilities we studied. If substantial reductions in
maternal mortality are to be achieved, universal coverage of life-saving interventions need to be
matched with comprehensive emergency care and overall improvements in the quality of
maternal health care. The MSI could be used to assess the performance of health facilities
providing care to women with complications related to pregnancy.

Conclusion

It is said that each year the deaths of 2 million babies are linked to complications during
birth and the burden is inequitably carried by the poor. Evidence-based strategies are urgently
needed to reduce the burden of intrapartum-related deaths particularly in low- and middleincome settings where 60 million women give birth at home. Although both Skilled Birth
Attendance and Emergency/or Essential Obstetric Care have the potential to reduce the number
of stillbirths seen globally. Further evidence is needed to be able to calculate an effect size. The
protocols that will be used was also cost effective by WHO standards and could save an
estimated 283000 newborn infants and 36600 mothers per year if implemented in rural areas of
74 Countdown countries. With the participation of at least a third of pregnant women and
adequate population coverage, women's groups practising participatory learning and action are a
cost-effective strategy to improve maternal and neonatal survival in low-resource settings. But
even in high-performance settings, there is scope to improve intrapartum care and especially
reduce impairment and disability. Addressing missed opportunities for births already occurring in
facilities could avert 36% of intrapartum-related deaths. Improved quality of care through drills

13

and audit are promising strategies. However, the majority of deaths occur in poorly performing
health systems requiring urgent strategic planning and investment to scale up effective care at
birth, neonatal resuscitation, and community mobilization as well as to develop, adapt, and
introduce tools, technologies, and task shifting to reach the poorest. Because the rate of neonatal
death in the 7 days after birth did not decrease after the introduction of Essential Newborn Care
training of community-based birth attendants, although the rate of stillbirths was reduced.
Subsequent training in the Neonatal Resuscitation Program did not significantly reduce the
mortality rates. High coverage of essential interventions did not imply reduced maternal
mortality in the health-care facilities studied. If substantial reductions in maternal mortality are to
be achieved, universal coverage of life-saving interventions need to be matched with
comprehensive emergency care and overall improvements in the quality of maternal health care.
The MSI could be used to assess the performance of health facilities providing care to women
with complications related to pregnancy. And with teenage pregnancy prevalent nowadays more
and more mothers first time mothers getting younger and younger is in a great position to benefit
on the improvements that would be allowed by the protocols implemented in EINC by the
selected RHUs of our study.

14

Chapter 3
Methodology

This chapter presents the methodology, the research design, the respondents, and the instrument
used to conduct the study.

Research Design

Research design is non-experimental study; specifically a descriptive research. It

approaches to determine the Protocol Review of Essential Intrapartum and Newborn Care among
selected lying-in centers which utilized the combination of qualitative method for data gathering.
The qualitative method employs questionnaire-checklists to determine if the EINC procedures
are implemented with high value of excellence.

Study Population

The population of the study will consist of two groups. The first group will be the
midwives and registered nurses of the selected lying-in centers and the second group will be the
postpartum mothers from June to August 2016. They will be selected as respondents to the
survey that will be conducted using a purposive sampling procedure.

Sampling Procedure

15

The procedure to be used is non-probability, specifically the purposive sampling. It is a

process of getting a sample available for the study wherein the respondents will be chosen
depending on the criteria prepared by the researchers in the selected lying-in centers.

Inclusion Criteria

The first group of respondents must be:

A resident of the selected barangay

A postpartum mother from 1st day of June to last day of December with normal
deliveries

Chosen regardless of age, marital status, and number of deliveries

The other group of respondents must be:

Midwives and registered nurses of the selected RHUs

Exclusion Criteria

The following respondents will be excluded from this study:

Mothers who had any complications during delivery such as

a) Sepsis
b) Cord coil
c) Premature birth

Have delivered at home

Have undergone caesarean section

Research Locale

The study will be conducted at Barangay Ayala and Canelar, Zamboanga City.

16

Data Gathering Procedure

The primary data to be used in the study will be sourced through the administration of a
well-structured questionnaire.
Data will be gathered using a questionnaire checklist divided into four parts regarding the
EINC practice; recommended newborn care practices, unnecessary newborn interventions,
recommended intrapartum care and unnecessary intrapartum interventions. The questionnaire
will be answered using a four point scale where the highest point will pertain to the great extent
the EINC practices are implemented and the lowest point will pertain to how poor the EINC
practices are implemented.

Statistical Analysis of the Data

Data collected will be tabulated, analyzed and interpreted as soon as the data is complete.

Ethical Consideration

In the conduct of the study, each participant will be given a consent, whereby confidentiality
of the information gathered will be stressed out. The principles namely respect for respondents
and justice will be observed. The consent will be translated in different language depending on
the level of understanding of the respondents.

17