The Philippines’ “Unang Yakap” (First Embrace):

Implementing an Integrated
Quality Improvement Practice for Newborn Health
and the Baby-Friendly Hospital Initiative (BFHI)
ANTHONY P. CALIBO, MD, DPPS
Officer-in-charge, Children’s Health Division, and Medical Specialist IV
National Program Manager for Newborn Care, and
Infant and Young Child Feeding (IYCF) Programmes
Disease Prevention and Control Bureau
Department of Health, Manila, Philippines
 Disclosure
• I declare that I have no conflicts of interests.
• I have no affiliation with any tobacco,
alcohol, pharmaceutical, vaccine and
biological products, other medical
commodities, the infant milk formula or food
industry, and maternal and baby accessories
or products.
 Outline of Presentation
1. To present linkages of newborn health and
early and exclusive breastfeeding initiation in
birth environments
2. To highlight the importance of hospitals,
other health facilities and birthing clinics as
environments of a newborn infant’s “first
food system”
3. To present the Philippines’ experiences in
integrating newborn care practices and BFHI
in the context of quality improvement for
maternal and newborn health services
Newborn Health and The Double Burden of Malnutrition
 System Enablers for Health, Food and
Nutrition – Baby-Friendly Hospital Initiative
• Health or hospital policy
• Management commitment and
governance
• Infrastructure and design
• Health care staff and health service
providers
• Hospital funds and resources Health facilities are
• Information management newborn infants’
• Quality improvement and period encounter with their
assessments “first food system.”
• Supportive care for patients –
mother and newborn dyads
 Tragedy of Newborn Deaths
• Total of 32 babies died in the
outbreak
Saturday, June 7, 2008 • This was considered and
handled as a hospital
Large Metro infection control problem
Manila hospital • Environmental cultures were
partially positive
closed for • Government inquiry done,
with World Health
cleanup Organization
• How much colostrum did the
25 babies reportedly cases receive?
died due to infection
 Newborn Deaths Comprise Almost 47-60% among
Infant Deaths in the Philippines, 1987-2017
100
Thousands

90

Deaths 29 days to 11 months Deaths 0-28 days

80

70

60

50

40

30

20

10

0
1986.5 1987.5 1988.5 1989.5 1990.5 1991.5 1992.5 1993.5 1994.5 1995.5 1996.5 1997.5 1998.5 1999.5 2000.5 2001.5 2002.5 2003.5 2004.5 2005.5 2006.5 2007.5 2008.5 2009.5 2010.5 2011.5 2012.5 2013.5 2014.5 2015.5 2016.5

YEARS
Estimates generated by the UN Inter-agency Group for Child Mortality Estimation (IGME) in
2017
 Causes of Newborn Deaths, Philippines, 2016
Others Pneumonia
Diarrhea 8% 6%
1%

Congenital
Anomalies
17%
Preterm
complications
31%

Tetanus Pneumonia
0%
Preterm complications
Intrapartum-related
Sepsis Sepsis
13% Tetanus
Congenital Anomalies
Diarrhea
Intrapartum-related
Others
24%

Estimates generated by the UN Inter-agency Group for Child Mortality Estimation

(IGME) in 2017
 Timelines and the Trend of Newborn Deaths in the
Philippines, 1957-2017
Establishment of the Local Government
Renaming of the Maternity Phil. Children’s Code of 1991 was
and Children’s Hospital, as Medical Center, 1979 passed
Call to National Policy
50 Dr Jose Fabella Memorial
Action on Newborn
Thousands

Hospital, 1968
45
MDGs Care, 2009

40 `
35

30

25 Rooming-in and
Breastfeeding Act Expanded
1992 – RA 7600 Promotion of
20
BF Act 2009 –
RA 10028
15

10

0
1956.5
1957.5
1958.5
1959.5
1960.5
1961.5
1962.5
1963.5
1964.5
1965.5
1966.5
1967.5
1968.5
1969.5
1970.5
1971.5
1972.5
1973.5
1974.5
1975.5
1976.5
1977.5
1978.5
1979.5
1980.5
1981.5
1982.5
1983.5
1984.5
1985.5
1986.5
1987.5
1988.5
1989.5
1990.5
1991.5
1992.5
1993.5
1994.5
1995.5
1996.5
1997.5
1998.5
1999.5
2000.5
2001.5
2002.5
2003.5
2004.5
2005.5
2006.5
2007.5
2008.5
2009.5
2010.5
2011.5
2012.5
2013.5
2014.5
2015.5
2016.5
Lower Median Upper

Estimates generated by the UN Inter-agency Group for Child Mortality Estimation (IGME)
in 2017
 Under-5 Mortality (U5MR) and Neonatal Mortality Rates
(NMR), Global and the Philippines, 1993-2017
100
Global - U5MR
90
PHL - U5MR
80
Per 1000 Live Births

Global - NMR
70
PHL - NMR
60

50 49.5
47.4 45.6
44 42.7
40 41.6 40.6 39.7
38.9 38.2 37.4
36.6 35.8 35
34.2 33.4 32.6
30 31.9 31.1 30.4
29.6 28.8 28
27.1
20
18 17.7 17.5 17.3 17.1 17 16.9 16.8 16.7 16.5 16.3 16.1 15.9
15.6 15.3 15 14.7 14.4 14.1 13.8 13.5 13.2 12.9
10
12.6

0
1993.5 1994.5 1995.5 1996.5 1997.5 1998.5 1999.5 2000.5 2001.5 2002.5 2003.5 2004.5 2005.5 2006.5 2007.5 2008.5 2009.5 2010.5 2011.5 2012.5 2013.5 2014.5 2015.5 2016.5

Estimates generated by the UN Inter-agency Group for Child Mortality Estimation (IGME)
in 2017
51-hospital study on newborn care practices in the
Philippines, 2011
 From Evidence to Policy … to Practice
• Unang Yakap - The Four
Core Steps in Immediate
Newborn Care will save
lives:
National Policy on Essential Newborn Care

Guideline
Development

Implementation
Dissemination
& Monitoring
 III IIII
Immediate Essential
Newborn Care Newborn Care
(The First 90 minutes) From 90 min to 6 hours

III
III IV
IV
Care Prior
Care after
To Discharge
Discharge
but after the first
To 7 days
90 minutes

V VI
VI
V
Enabling
Additional
The
Care
Environment

VII
VII
Equipment
And Supplies
Maintenance
Checklist
14
Practice Guidelines on Intrapartum and
Immediate Postpartum Care

• Updated, evidence based national

guideline on intrapartum and
immediate postpartum care

• Intended for use by health

professionals (OB Specialists, OB
Practitioners, Nurses, Midwives) in
all GOVERNMENT & PRIVATE health
facilities
 Unang Yakap – Yakap ng Ina, Yakap ng Buhay
(First Embrace – Embrace of the Mom, Embrace of Life)

Health Sector
Reform
Agenda

Network of
Centers of
Excellence

Curriculum
Changes

Social
Marketing
Campaign
 Four Pillars to Scale-Up Implementation of
Essential Intrapartum and Newborn Care

Network of
Health Sector
Centers of
Reform Agenda
Excellence

Curriculum Social Marketing

Changes Campaign
 Scale-Up Implementation of Essential Intrapartum and
Newborn Care (EINC) Project 2010-2011

Health Sector
Reform
Agenda

Network of
Centers of
Excellence

Curriculum
Changes

Social
Marketing
Campaign
 Scale-Up Implementation of Essential Intrapartum and
Newborn Care (EINC) Project 2010-2011

Health Sector LUZON (8): QMMC, Fabella,

Reform
Agenda Jose Reyes, East Avenue,
Tondo Med, Malabon
Network of (SLRWH), Caloocan
Centers of (DJNRMH), PGH
Excellence

Curriculum
VISAYAS (1): EVRMC
Changes
MINDANAO (2):
Social GenSan City Hospital,
Marketing Cotabato Regional &
Campaign Med Center
 Unang Yakap and the EINC Scale-Up:
First National Initiative for Quality Improvement
for Maternal and Newborn Health Services

• Use of third party conveners contracted by Philippines

Department of Health (DOH) and the WHO
• Engagement of hospital management and local
government unit chief executives
• Weekly review and assessment of progress
• Hospital-wide scale-up to increase aware and practice
reforms
• Planning workshops
 Hospital Management Teams for Quality Improvement
of Maternal and Newborn Health Services

Hospital Chief Ruben Flores of Hospital Chief Ligaya Estrella of Hospital Chief Vicente Dela Cruz
Dr. Jose Fabella Memorial San Lorenzo Ruiz Women’s of Tondo Medical Center
Hospital Hospital

http://eincbulletin.blogspot.com/
 From Two-day Quality Assurance Workshop on
Essential Intrapartum and Newborn Care (EINC),

then integrated in the

20-hour Integrated Essential Maternal and Newborn Care, and

Lactation Management Course as part of Mother-Baby Friendly
Hospital Initiative (MBFHI)
 Political Engagement and Social Mobilization for Quality
Improvement of Maternal and Newborn Health Services
Fomer Department of Health Family Health Office Director
Honorata Catibog during the Advocacy Partners Forum for Essential
Intrapartum and Newborn Care

Gathering of health workers in General Santos

City, Central Mindanao
Mobilization of academic professional organizations for
pre-service education (nurses, midwives, physicians)
http://eincbulletin.blogspot.com/
Integrating Essential Maternal and Newborn Care
(Unang Yakap) and BFHI
• Hospital policies are anchored on
national laws and Department of Health
issuances, including the Milk Code
(Executive Order 51)
• Hospital-wide capacity development
effortlessly incorporates “Unang Yakap”
with the 10 Steps including Mother
Friendly Criteria
• Prenatal education and birth plans
empowers couples to demand Unang
Yakap, the 10 Steps and Mother Friendly
Care
Integrating Essential Maternal and Newborn Care
(Unang Yakap) and BFHI
• Periods of labor, intrapartum and childbirth
are seamlessly linked with Unang Yakap,
the 10 Steps and Mother-Friendly Care
• Non-separation of mother and her newborn
are strictly observed
• Philippine Heath Insurance Corporation
(PhilHealth) supports these through its
benefit packages
 Maternity Care Package
 Normal Spontaneous Delivery Package
 Cesarean Section Package
 Newborn Care Package
 Z-Benefit Package for Preterm and Small
Newborn Infants
Philippines’ Early and Exclusive Breastfeeding Initiation Rates,
2003-2017, including Skin-to-Skin Contact
2013-17, NDHS/FHS, PSA
80.0
72.7

70.0 66.0
Proportion of Newborns Infants, %

63.7

60.0
56.9
54.0 53.5
49.7
50.0

40.0

30.0

20.0

10.0

0.0
2003 2008 2011 2013 2017
Breastfeeding Initiation Skin-to-Skin Contact
Trend in breastfeeding initiation rates of children born in the last 24 months who were put to the breast within one hour* (NDHS 2003-2017;)
Trend in the proportion of newborns that had skin-to-skin contact with the mother within one hour of delivery (Family Health Survey 2011, and NDHS
2013, 2017)

29
 Ongoing initiatives for Newborn Health,
IYCF and (M)BFHI in the Philippines
• Sub-national roll-out implementation of the Care for
the Small Babies to address quality of care for preterm
and low birth weight newborn infants
• Strengthening Department of Health Mother-Baby
Friendly Hospital Initiative (DOH MBFHI) Sub-national
Assessors (DOH Center for Health Development –
Regional Offices) on integrating essential maternal and
newborn care, 10 Steps to Successful Breastfeeding,
Mother Friendly Care, and Care for Small Babies
• Health systems strengthening for end-referral facilities
trained on care for the small babies to be contracted by
the Philippine Health Insurance Corporation to
implement the Z Benefit Package (with development
partner technical assistance)
 Ongoing initiatives for Newborn Health,
IYCF and (M)BFHI in the Philippines
• Empower sub-national level task forces on Monitoring
of the Implementation and Enforcement of the Milk
Code and the Expanded Promotion of Breastfeeding Act
• Maintaining functionality of the Mother-Baby Friendly
Philippines reporting platform and App for Milk Code
and Expanded Promotion of Breastfeeding Act and
scaling up roll out implementation (with development
partner technical assistance)
• Finalization of the National Strategic Plan on Infant and
Young Child Feeding 2019-2030 (IYCF 2030)
• Updating of the Newborn Action Plan for the
Philippines
• Developing the National Strategy for Child Health and
Development: Survive, Thrive and Transform
Trends in Childhood Mortality,
2017 NDHS, PSA
Deaths per 1,000 live births for the 5-year period before the survey

54
Under-5 mortality
48
40
34 35 34
29 31
25 27
Infant mortality 23 21

18 18 17 16
Neonatal mortality 13 14

1993 1998 2003 2008 2013 2017

NDS NDHS NDHS NDHS NDHS NDHS
 Summary
• Health facilities are important contributors for a
newborn infant’s entrance and access to the
his/her food system
• The newborn infant’s need to survive distinguishes
its requirement beyond the “food system” and the
need to integrate the health and nutrition system in
the overall equation
• Implementation of the Baby Friendly Hospital
Initiative (BFHI) has to be contextualized to the
country’s needs to address SDG targets, newborn
mortality reduction, and improving initiation of
early and exclusive breastfeeding
MARAMING SALAMAT PO!