Second biennial progress report : 2016-2017 (Action Plan for Health Newborn Infants in the Western Pacific Region : 2014-2020)

second biennial progress report (2016–2017) ACTION PL AN FOR HEALTHY NEWBORN INFANTS IN THE WESTERN PACIF IC REGION (2014 –2020 )

second biennial progress report (2016–2017) ACTION PL AN FOR HEALTHY NEWBORN INFANTS IN THE WESTERN PACIF IC REGION (2014 –2020 ) The views expressed in this report are those of the participants in the Second Biennial Meeting on Accelerating Progress in Early Essential Newborn Care (EENC) held in Da Nang, Viet Nam from 14 to 17 August 2017, and do not necessarily reflect the policies of the World Health Organization. This report has been prepared by the World Health Organization Regional Office for the Western Pacific to document the status of Early Essential Newborn Care in the Western Pacific Region and country plans for accelerating progress in the next biennium, based on the outcome of discussions in Da Nang, Viet Nam. © World Health Organization 2018 ISBN 978 92 9061 849 2 Some rights reserved. This work is available under the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo). 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Suggested citation.Second biennial progress report: 2016-2017 (Action Plan for Health Newborn Infants in the Western Pacific Region: 2014-2020). Manila. World Health Organization Regional Office for the Western Pacific. 2018. Licence: CC BY-NC-SA 3.0 IGO. Cataloguing-in-Publication (CIP) data. 1. Infant, Newborn. 2. Infant care. 3. Research report. I. World Health Organization Regional Office for the Western Pacific. (NLM Classification: WS420). Sales, rights and licensing. To purchase WHO publications, see http://apps.who.int/bookorders. To submit requests for commercial use and queries on rights and licensing, see http://www.who.int/about/licensing. For WHO Western Pacific Regional Publications, request for permission to reproduce should be addressed to Publications Office, World Health Organization, Regional Office for the Western Pacific, P.O. Box 2932, 1000, Manila, Philippines, Fax. No. (632) 521-1036, email: wpropuballstaff@who.int. Third-party materials. 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Photo credits : © WHO Contents Acknowledgements ............................................................................................................................................................................................... iv Abbreviations ................................................................................................................................................................................................................ vi Foreword ..........................................................................................................................................................................................................................vii Highlights – Early Essential Newborn Care (EENC) since 2015 ..................................................................................viii 1. Introduction ........................................................................................................................................................................................................1 2. Benchmarks of EENC scale-up readiness ..........................................................................................................................5 3. Health facility EENC standards .....................................................................................................................................................9 4. Tracking hospital impact ..................................................................................................................................................................25 5. EENC intervention coverage and population impact ...................................................................................27 6. Accelerating progress towards universal adoption of EENC................................................................31 7. Priority actions to consolidate gains and further scale up EENC in the next biennium .............................................................................................................................................................................33 References ..................................................................................................................................................................................................................35 Annexes » Annex 1. Early Essential Newborn Care (EENC)...........................................................................................................38 » Annex 2. EENC Monitoring and Evaluation Framework (2015–2020) ..................................................41 » Annex 3. Validation of EENC monitoring and evaluation data from eight priority countries ................................................................................................................................ 48 » Annex 4. EENC population coverage indicators ..........................................................................................................53 » Annex 5. EENC country profiles ..................................................................................................................................................55 » Annex 6. Chair's Statement of the High-level Forum on Accelerating Progress in Early Essential Newborn Care ........................................................................................................................72 second BIENNIAL PROGRESS REPORT (2016–2017) iv ACKnoWLeDGeMents The Reproductive, Maternal, Newborn, Child and Adolescent Health unit of the World Health Organization (WHO) Regional Office for the Western Pacific and the United Na- tions Children’s Fund (UNICEF) East Asia and Pacific Regional Office would like to thank all those who participated in the Second Biennial Meeting on Accelerating Progress in Early Essential Newborn Care (EENC) in Da Nang, Viet Nam, on 14–17 August 2017 and who contributed to the collection, review and analysis, and validation of EENC country data, and to the development of this Biennial Progress Report as follows. COuNTRy STAff: BiENNiAl REViEW We would like to begin by thanking the Ministry of Health of Viet Nam that hosted the meeting. Viet Nam – From the Ministry of Health: Professor Nguyen Viet Tien, Vice Min- ister of Health; Dr Nguyen Duc Vinh, Director, Maternal and Child Health Department; Mr Hoang Anh Tuan, Officer, Maternal and Child Health Department. Cambodia – From the Ministry of Health: Professor Chhour Y Meng, Undersecretary of State for Health; Dr Sophonneary Prak, Deputy Director, National Maternal and Child Health Centre; Dr Po Sok, Deputy Director of Hospital Services Department; Dr Sidonn Krang, Vice-Chief, Prevention and Control Bureau, Communicable Disease Control Department. China: Ms Hong Li, Principal Staff Member, Senior Staff, Department of Maternal and Child Health, National Health and Family Planning Commission; Ms Jun Liu, Head Nurse, Obstetrical Department, Peking University First Hospital Women and Children Health Center; Dr Shan Zhang, Physician, Neonatal Intensive Care Unit, Bayi Children's Hospital, affiliated with The Army General Hospital of People’s Liberation Army. Lao People's Democratic Republic – From the Ministry of Health: Associate Professor Bounnack Saysanasongkham, Director General, Department of Health Care and Rehabili- tation; Dr Sommana Rattana, Chief, Administration Unit, Department of Health Care and Rehabilitation; Professor Douangdao Soukaloun, Deputy Director of Mahosot Hospital. Mongolia: Dr Byambasuren Lamjav, Vice-Minister of Health, Ministry of Health; Dr Buyanjargal Yadamsuren, Director, Department of Medical Service, Ministry of Health; Dr Battulga Dorjsuren, Head, Division of Health Policy Research and Management Train- ing, Center for Health Development; Dr Enkhtsetseg Jamsranjav, Lecturer, Department of Obstetrics and Gynecology, Mongolian National University of Medical Sciences, and Secretary, Ministry of Health Professional Council for Obstetrics and Gynecology. vPapua New Guinea – From the National Department of Health: Dr Edward Waramin, Acting Manager, Family Health Services; Mr Maluo Magaru, Acting Adviser, Child Health; Mrs Freda Walai Sui, Programme Officer, Newborn Care. Philippines – From the Department of Health: Dr Herminigildo Valle, Undersecretary of Health, Office for Field Implementation and Management; Dr Maria Francia Laxamana, Assistant Secretary of Health, Office for Technical Services; Dr Joshua Brillantes, Director III, Regional Office IX; Dr Maria Joyce Ducusin, Medical Officer V, Officer-in-Charge, Direc- tor III, Family Health Office, Disease Prevention and Control Bureau; Dr Francisco Mateo, Director III/ Officer-in-Charge, Regional Officer XII; Dr Anthony Calibo, Officer-in-Charge, Child Health Division, National Newborn Care Programme Manager, Disease Prevention and Control Bureau. Solomon Islands – From the Ministry of Health and Medical Services: Dr Nemia Bainivalu, Undersecretary; Dr Joel Denty, Provincial Health Director, Guadalcanal Province; Dr Divinal Ogaoga, Director, Reproductive and Child Health Division; Mrs Anna Jatobatu, National Newborn Health Coordinator, Reproductive and Child Health Division. iNDEPENDENT REViEW GROuP Dr Elizabeth Mary Mason, Independent Consultant and Honorary Fellow, Institute for Global Health, University College London, United Kingdom of Great Britain and Northern Ireland; Dr Hiromi Obara, Japan International Cooperation Agency (JICA) Health Policy Adviser, Lao People’s Democratic Republic; Ms Pamela Putney, International Health Consultant, United States of America; Dr Maria Asuncion Silvestre, President, Kalusugan ng Mag-Ina Inc., Phil- ippines; Dr Hoang Thi Tran, Deputy Director, Da Nang Hospital for Women and Children, Viet Nam; Dr Xu Tao, Vice Director of the Child Health Care Department, National Center for Women and Children’s Health of the Chinese Center for Disease Control and Prevention, China; Dr John Murray, Consultant, International Health. OBSERVER ORGANizATiONS Alive and Thrive Southeast Asia, Viet Nam; Department of Health, Australia; GIZ (Deutsche Gesellschaft für Internationale Zusammenarbeit), Cambodia; Japan International Coopera- tion Agency (JICA) headquarters, Japan; JICA, Cambodia; JICA, Lao People’s Democratic Republic; Jigme Dorji Wangchuk National Referral Hospital, Khesar Gyalpo University of Medical Sciences, Bhutan; Korea Foundation for International Health Care, Cambodia; Min- istry of Health, Viet Nam; National Center for Global Health and Medicine, Japan; Save the Children, Cambodia; Save the Children, Viet Nam; St. Luke's International University, Japan. Lastly, we wish to acknowledge the contributions of staff from WHO and UNICEF country offices in the Western Pacific Region. AbbreviAtions AiR annual implementation review CHERG Child Health Epidemiology Reference Group CPAP continuous positive airway pressure CRVS civil registration and vital statistics DHS Demographic and Health Survey EENC Early Essential Newborn Care HMiS health management information system iGME United Nations Inter-agency Group for Child Mortality Estimation KMC Kangaroo Mother Care lBW low birthweight MCH maternal and child health MiCS Multiple Indicator Cluster Survey NCu neonatal care unit PPH postpartum haemorrhage SDGs Sustainable Development Goals STS skin-to-skin uHC universal health coverage uNiCEf United Nations Children’s Fund WHO World Health Organization second BIENNIAL PROGRESS REPORT (2016–2017) vi vii ForeWorD The World Health Organization (WHO), United Nations Children’s Fund (UNICEF), Mem- ber States and stakeholders in the Western Pacific Region share a vision for mothers and their children: that every newborn infant has the right to a healthy start in life. But one newborn infant dies every two minutes – often needlessly – in the Region. Together, we have taken bold steps to address this grim statistic, with Member States endorsing the Action Plan for Healthy Newborn Infants in the Western Pacific Region (2014–2020). The plan aims to improve the quality of childbirth and newborn care in health facilities, where the vast majority of births occur in the Region. Member States reported important accomplishments in improving care in the two years following the launch of the action plan, as outlined in the First biennial progress report of the action plan. This Second biennial progress report shows further impressive results achieved in 2016 and 2017, thanks to the dedication of Member States, health providers and development partners. Early Essential Newborn Care (EENC) has been introduced in more than 3360 health facilities with 30 251 health facility staff coached. Cambodia and the Philippines have achieved the action plan target of 80% of facilities introducing EENC. Coverage of life-saving interventions for term babies has also increased significantly: 75% of term babies are placed in immediate skin-to-skin contact with their mothers after birth, and 85% are exclusively breastfed in the immediate newborn period. Still, we cannot rest on these successes. Assessments of care reveal that evidence-based practices are often not applied during antenatal care and childbirth. Unnecessary caesarean sections are common, and only one in four babies born by caesarean section benefit from skin-to-skin contact. Preterm babies, who account for half of all newborn deaths, are unnecessarily separated from their mothers before receiving EENC – increasing their risk of poor health. We need to accelerate our efforts to leave no mother and child behind. Together, we, the governments, WHO and UNICEF, must push to meet the Sustainable Development Goal target of a global maternal mortality ratio of fewer than 70 deaths per 100 000 live births with no country above 140; and the regional neonatal mortality rate target of 10 or fewer deaths per 1000 live births in countries. To reach these ambitious targets, we will work with Member States and partners to ensure universal coverage of high-quality EENC. Shin Young-soo, MD, Ph.D. Karin Hulshof Regional Director Regional Director World Health Organization United Nations Children’s Fund Western Pacific Region East Asia and the Pacific second BIENNIAL PROGRESS REPORT (2016–2017) viii HiGHLiGHts Early Essential Newborn Care (EENC) since 2015 Eight priority countries with the highest burden of newborn deaths a met in August 2017 to review progress in implementing the Action Plan for Healthy Newborn Infants in the Western Pacific Region (2014–2020). By August 2017, 3366 facilities had introduced Early Essential Newborn Care (EENC) and 30 251 staff had been coached, with Cambodia and the Philippines achieving the regional Action Plan target of 80% of facilities adopting EENC. Term babies had improving rates of immediate skin-to-skin (STS) contact (75%), sustained STS contact until the first breastfeed (57%) and exclusive breastfeeding (85%). EENC teams had been formed by 55% of hospitals, a dramatic improvement from 2015, but only 19% conducted the routine quality of care assessments essential for sustain- ing practice.b Most countries had appointed EENC coordinators, adapted the clinical practice pocket guide, formed national EENC working groups and conducted regular data reviews. However, incorporation of EENC into pre-service curricula has lagged. Better antenatal and delivery care is needed EENC assessments have revealed low rates of syphilis (32%) and HIV testing (55%), use of the partograph (59%), non-supine position during the second stage of labour (50%), companion of choice during childbirth (24%) and early postnatal use of oxy- tocin to prevent bleeding (79%). Unnecessary and potentially harmful procedures such as enema (25%) persist. a. Cambodia, China, the Lao People's Democratic Republic, Mongolia, Papua New Guinea, the Philippines, Solomon Islands and Viet Nam. b. Estimated from a random sample of EENC-implementing hospitals across eight countries (n = 178). ix BaBies Born preterm or By caesarean section are not receiving sufficient eenc Preterm babies account for half of all newborn deaths but are less likely than term babies to receive immediate STS contact (56%), breastfeeding before separation (29%) and exclusive breastfeeding (69%). Kangaroo Mother Care (KMC) was received by 35% of preterm babies, an increase from 7% in 2015, but only 15% received it for at least 18 of the previous 24 hours. Overuse of caesarean section remains common in many countries but only 26% babies born by caesarean section receive EENC. High rates of separation of stable preterm babies and babies born by caesarean section for observation increases risk of hypothermia, infection and death. the Western pacific high-level forum on accelerating progress in eenc On 16–17 August 2017, high-level representatives from priority countries met to identify steps towards universal adoption of EENC. The group committed to con- tinue support for EENC, particularly for preterm and low-birthweight (LBW) babies and those born by caesarean section, and noted that improved collaboration and coordination will be central to further progress (Box 1) (1). Box 1. high-level forum on accelerating progress in early essential newborn care At this landmark forum on 16–17 August 2017, vice-ministers of health, undersecre- taries and assistant secretaries of health, and representatives from the eight priority countries outlined their approach to ensuring that EENC is adopted and sustained. continued advocacy is essential for sustaining resources. Although most countries are fi nancing many aspects of EENC scale-up using local resources, continued ad- vocacy is needed to ensure increased allocation of government resources for EENC. Quality-of-care approaches need continued support. Mechanisms to improve and sustain quality are essential, including upgrading pre-service training curricula, an area that has not yet received enough attention; formation of hospital EENC teams to conduct self-monitoring of quality of childbirth and newborn care; facil- ity accreditation systems that include EENC practice standards; and maternal and child health (MCH) insurance policies that reimburse providers for practising EENC. over-medicalization is a major problem in most countries in the region, causing preventable morbidity, mortality and expenditure. Overuse of caesarean section and over-admission of stable neonates to neonatal care units remain very common. This trend results from many factors including rapid economic growth, aggressive efforts by commercial interests to promote the use of medical products and devices, and policies that allow institutions or staff to receive additional reimbursement for unnecessary procedures (confl icts of interest). While it is recognized that adoption and use of technology can have many benefi ts, it is also essential that ineffective, harmful and cost-ineffective practices be limited by strong regulation and policy guidance. marketing of breast-milk substitutes remains rampant and is a challenge to in- creasing breastfeeding rates. Combating this problem will require enforcement of marketing laws, strict application of facility breastfeeding standards through accreditation and other methods, improved maternity leave and workplace legisla- tion to support longer and exclusive breastfeeding. engaging professional associations and civil society organizations will be important for further scale-up. Engagement of professional associations and civil partners is essential for building community acceptance. Demand for EENC will be an impor- tant area to emphasize in the next phase. x second BIENNIAL PROGRESS REPORT (2016–2017) 1regional vision: a healthy start for every newborn A newborn dies every two minutes in the World Health Organization (WHO) West- ern Pacifi c Region (2). In response, the Action Plan for Healthy Newborn Infants in the Western Pacifi c Region (2014–2020) was developed by the WHO Regional Offi ce for the Western Pacifi c, the United Nations Children's Fund (UNICEF) Regional Offi ce for East Asia and the Pacifi c, Member States and experts, and endorsed in October 2013 by the WHO Regional Committee for the Western Pacifi c (3,4). Eight priority countries with the highest burdens of maternal and neonatal mortality – Cambodia, China, the Lao People’s Democratic Republic, Mongolia, Papua New Guinea, the Philippines, Solomon Islands and Viet Nam – are implementing the Action Plan by scaling up Early Essential Newborn Care (EENC) (Annex 1). Funda- mental to EENC is improving the quality of skilled delivery and post-delivery care, while also improving access to facility-based services for mothers and newborns. introducing, sustaining and scaling up eenc: a regional approach Based on extensive country experience, an approach evolved to introduce, sustain and scale up EENC. introduction 1 8 PRIoRITY coUnTRIes account for 96% of neonatal deaths In THe WesTeRn PacIFIc ReGIon ReaLITY cHecK CAMBODIA VIET NAM CHINA LAO PEOPLE’S DEMOCRATIC REPUBLIC PHILIPPINES MONGOLIA SOLOMON ISLANDS PAPUA NEW GUINEA 2First, facility health providers are coached on routine delivery and newborn care using Early Essential Newborn Care Module 2 – Coaching for the First Embrace for breathing and non-breathing babies (5). Once established, multidisciplinary hospital EENC teams use Early Essential Newborn Care Module 3 – Introducing and sustain- ing EENC in hospitals: routine childbirth and newborn care to: (1) assess their own hospital practices, policies, supplies and environmental hygiene to identify strengths and areas for improvement; (2) develop short-term action plans based on findings; and (3) monitor plan implementation and re-assess periodically (6). When coaching and quality improvement for routine childbirth and immediate newborn care are established, Early Essential Newborn Care Module 4 – Introduc- ing and sustaining EENC in hospitals: Kangaroo Mother Care for preterm and low- birthweight infants is added to assess facility readiness and the development of an action plan (7). Following this is clinical coaching on KMC. KMC has historically been difficult to establish in the past because of lack of adequate staff, space and beds, and reluctance by decision-makers. Thus, hospital staff members use data to prepare and secure essential support from senior hospital decision-makers prior to KMC clinical coaching. Finally, Early Essential Newborn Care Module 5 – Introducing and sustaining EENC in hospitals: Managing childbirth and postnatal complications is added to address maternal complications. Quality of care in health facilities is further assessed using Early Essential Newborn Care Module 1 – Annual implementation review and planning guide (8). Ministries of Health lead an external team to assess quality of childbirth and newborn care in health facilities that have introduced EENC. These assessments inform programme planning (Box 2). moving towards evidence-based practice: data driving change The Early Essential Newborn Care Monitoring and Evaluation Framework (2015–2020) was developed to help countries measure progress in EENC (Annex 2). At the first biennial review of regional progress in 2015, priority countries had shown impressive progress, with over 25 000 health workers in about 2000 health facilities coached in EENC (9). Policy-makers and programme managers acknowledged the power of data to understand and change practices and to mobilize political support and resources. Data became central to development of country biennial road maps for scaling up EENC (10). second BIENNIAL PROGRESS REPORT (2016–2017) 3For the second biennial EENC progress meeting, the eight priority countries reported data on indicators in the framework in April and May 2017. The EENC Independent Review Group (IRG), comprised of experts in midwifery, neonatology, and obstet- rics and gynaecology, validated the data (Annexes 3, 4). Final data were used to develop country profiles (Annex 5). Participants from priority countries discussed progress at the Second Biennial Meet- ing on Accelerating Progress in EENC, in Da Nang, Viet Nam, on 14–17 August 2017, which is summarized in this report (Annex 6). Box 2. regional approach to introducing, sustaining and scaling up eenc in hospitals action programme approach policy support clinical coaching to strengthen staff practices (eenc modules 2, 4 and 5) Two-day clinical coaching in a delivery room setting to improve practices using accredited facilitators focused initially on routine management of breathing and non-breathing babies (5). Coaching on Kangaroo Mother Care (KMC) (7) and the management of maternal complications is added when the facility is ready. Early Essential Newborn Care Clinical Practice Pocket Guide (11) adapted for local use ensures policies and protocols are consistent with evidence-based standards. multidisciplinary eenc hospital teams to improve collaboration (eenc module 3) Hospital teams formed to ensure close collaboration between obstetrics/midwifery and paediatrics and to oversee quality improvement and scale-up (6). Ministry of Health issues a formal directive on composition and roles of the team. Hospital directors establish and endorse teams and require regular meetings. hospital self-monitoring to improve quality of care (eenc modules 3, 4 and 5) Teams are oriented in the EENC quality improvement approach and conduct regular assessments to identify gaps and develop solutions tailored to local situations and resources (6). Hospital directors and senior clinical staff adapt or modify hospital protocols, change environments and organization, and make essential supplies or equipment available. annual implementation reviews to inform programming (eenc module 1) Six-day national annual (or biennial) implementation reviews (AIRs) of facilities collect data on practices and facility medicines, supplies and environments so that action can be taken quickly to address gaps (8). Staff at national, subnational and hospital levels use data to identify changes required in policies, protocols, standards and other systems support needed to accelerate scale- up, address gaps and secure funding from national, subnational or hospital budgets. second BIENNIAL PROGRESS REPORT (2016–2017) 4 5Ten benchmarks are used to assess the status of policy and planning measures that are important for introducing and supporting EENC. Four priority countries provided data for all 10 benchmarks and the others for nine benchmarks, with data available for 95% of benchmarks overall. Eighty-nine per cent of benchmarks achieved or partially achieved were validated (Table A3.1 in Annex 3). Five countries have achieved seven or more benchmarks, one achieved six, one fi ve and one three. Six countries have completed a newborn health situation analysis, appointed a newborn health focal person in the ministry of health, adapted the Early Essential Newborn Care Clinical Practice Pocket Guide (11) and conducted AIRs for EENC (Fig. 1). The least-achieved benchmarks remain establishment of an EENC stakeholder group and incorporation of EENC interventions into pre-service curricula. Benchmarks of eenc scale-up readiness 2 FULL-TIME NEWBORN HEALTH FOCAL PERSON IN THE MINISTRY OF HEALTH FUNDED 12-MONTH & 5-YEAR ACTION PLANS EENC INCLUDED IN PRE-SERVICE TRAINING CURRICULA BencHMaRKs FoR scaLInG UP and sUsTaInInG eenc second BIENNIAL PROGRESS REPORT (2016–2017) 6 Improvements in benchmark status between 2015 and 2017 were most signifi cant for adaptation of the EENC Clinical Practice Pocket Guide (four countries), AIRs and professional associations' support for EENC (three countries each) (Fig. 2). A decline in benchmark status was noted for development of a fully funded 12-month EENC action plan and establishment of a stakeholder group, while regular meetings of the national EENC working group showed no change. In 2015, four countries reported that the proportion of EENC interventions incorporated into pre-service curricula was in the 62–92% range for medical curricula, 39–62% for nursing and 39–96% for midwifery. However, in 2017 no country reported updated data on incorporation of EENC into pre-service curricula. 10 BencHMaRKs FoR eenc PRePaRedness In THe 8 PRIoRITY coUnTRIes 1 2 3 4 5 6 7 8 1. Newborn health situation analysis 2. Costed fi ve-year action plan 3. Funded 12-month implementation plan 4. National EENC working group meets regularly 5. Full-time newborn health focal person 6. EENC stakeholder group 7. Clinical practice pocket guide adopted 8. Conducted annual implementation review 9. Mechanisms for professional associations' support for EENC 10. EENC included in pre-service training curricula BENCHMARK achieved partially achieved not achieved no data 1. CAMBODIA – 2. CHINA – 3. LAO PEOPLE'S DEMOCRATIC REPUBLIC – 4. MONGOLIA – 5. PAPUA NEW GUINEA – 6. PHILIPPINES 7. SOLOMON ISLANDS – 8. VIET NAM figure 1. Status of the EENC scale-up readiness benchmarks by country, October 2017 0 1 2 3 4 5 6 7 8 figure 2. Number of eight priority countries achieving EENC scale-up readiness benchmarks, 2015 and 2017 7 2015 Partially included Partially included Number of countries achieving benchmark 2017 Newborn health situation analysis National EENC working group meets regularly Clinical practice pocket guide adopted Costed fi ve-year action plan Full-time newborn health focal person Conducted annual implementation review Funded 12-month implementation plan EENC stakeholder group Mechanisms for professional associations' support for EENC EENC included in pre-service training curricula 8 9Implementation of EENC is defi ned by 13 health facility standards (Annex 2). Stand- ards have been updated since 2015 to add practice measures for preterm and LBW babies and routine delivery care. Across the eight countries, data were fully available for 65% of heath facility stand- ard indicators, with an additional 31% partially available. Ninety-fi ve per cent of the indicators were validated (Table A3.2 in Annex 3). Progress with facility standards is summarized in fi ve areas: (1) EENC clinical coach- ing and hospital teams; (2) routine antenatal and delivery practices; (3) immediate newborn care for term, preterm and LBW babies; (4) environmental hygiene prac- tices; and (5) essential medicines and commodities. eenc clinical coaching and hospital teams Across the Western Pacifi c Region, 3366 facilities have introduced EENC, including 7% of national and regional hospitals, 13% of fi rst-level referral hospitals and 14% of fi rst-level facilities1 (Fig. 3). Excluding China, where EENC has been launched in 1. National- and regional-level facilities offer services of fi rst-level referral plus advanced neonatal care including continuous positive airway pressure (CPAP), serve as teaching hospitals and provide support to lower-level facilities. First-level referral facilities offer services of fi rst- level plus management of preterm labour and common complications of prematurity (e.g. oxygen), complications of delivery including assisted delivery and caesarean sections. First-level facilities where deliveries take place should have the capacity for care of breathing and non-breathing babies. health facility eenc standards 3 30 251 HeaLTH FacILITY sTaFF have been coached in eenc: a 9% increase from 2016 3366 HeaLTH FacILITIes have introduced eenc: a 17% increase from 2016 There continues to be signifi cant progress in scale-up of eenc second BIENNIAL PROGRESS REPORT (2016–2017) 10 six hospitals, EENC has reached 84% (134/159) of national and regional hospitals, 58% (1190/2060) of fi rst-level referral and 27% (2036/7628) of fi rst-level facilities in the other seven priority countries. Cambodia and the Philippines have reached the regional Action Plan target of 80% of all facilities introducing EENC (Table 1). However, quality of care continues to need improvement. The total number of staff coached across the Region has also shown rapid progress since 2012 (Table 1, Fig. 4). In facilities implementing EENC, 30 251 providers responsible for childbirth, newborn and postnatal care have been coached, a 9% increase from 2016, including 62% at the national and regional levels, 58% in fi rst-level referral and 63% of providers in fi rst-level facilities (data by facility level figure 3. Total number of health facilities providing childbirth services that have introduced EENC, by country, 2016–2017 1200 1100 1000 900 800 700 600 500 400 300 200 100 0 N um be r o f h ea lth fa ci lit ie s pr ov id in g ch ild bi rt h se rv ic es th at h av e in tr od uc ed E EN C camBodia china mongolia philippines viet namsolomon islands 91% 12% 78% 48% 29% 3% 14% 12% 62% 8% 89% 18% 53%53% 1137 687c 875 687c 1093 23 papua neW guinea lao people's dem. rep. a. The total number of health facilities providing childbirth services increased from 1246 in 2016 to 1272 in 2017. b. The total number of health facilities in China is 25 860. Data are not available on the number of these facilities offering childbirth services. Six hospitals in China began EENC coaching in 2016. c. Number is an underestimate as EENC has been introduced in fi rst-level facilities in Viet Nam; however, data on the exact number are not available. 1139a 53 49 49 2016 2017 145 194 11 95 6b6b 11 are not available for some countries). Coaching coverage of target staff in facilities implementing EENC is over 80% in China. Fifty-five per cent of hospitals have es- tablished an EENC team, a dramatic increase from 22% in 2016.2 However, 19% of established teams met standards for implementing a quality-improvement approach.3 2. Estimated from a random sample of EENC-implementing hospitals across eight countries, n = 153 in 2016 and n = 178 in 2017. 3. Quality-improvement approach consists of: (1) regular and documented meetings of the EENC team; (2) at least two EENC assessments per year; and (3) developing and updating an EENC hospital action plan at least quarterly. figure 4. Total number of health facility staff coached in EENC by year and by country, 2010–2017 china papua neW guinea solomon islands viet nam mongolia lao people's dem. rep. camBodia philippines N um be r o f h ea lth fa ci lit y st af f c oa ch ed in E EN C 2010 20142011 20152012 20162013 2017 35 000 30 000 25 000 20 000 15 000 10 000 5 000 0 second BIENNIAL PROGRESS REPORT (2016–2017) 12 Scale-up has occurred most rapidly in countries with a cadre of strong hospital facilitators who lead coaching roll-out (see Box 3 for an overview of the scale-up approach in Viet Nam). Because an emphasis has been placed on ensuring coaching quality for practice change, EENC facilitators must be nationally accredited before coaching on their own. Accreditation requires staff to complete basic EENC coach- ing, an additional day of facilitator instruction and then at least one coaching ses- sion under supervision. For this reason, increasing scale-up requires investments in building a cadre of facilitators at the national and subnational levels. Since coaching is conducted in hospitals by local staff over two days, it does not incur costs associ- ated with traditional off-site training. Accredited facilitator 6:1 participants- to-facilitator ratio Two days full-time practice in delivery rooms Pre- and post-coaching assessments to document practice change Maintaining the quality of eenc coaching is critical to changing practice 13 taBle 1. Proportion of health facilities that have introduced EENC and of staff coached, by country, June 2017 Proportion of health facilities providing childbirth services that have introduced EENC Proportion of staff coached in health facilities that have introduced EENC COUNTRY System level System level National/ Regional First-level referral First-level TOTAL National/ Regional First-level referral First-level TOTAL CAMBODIA 83.0% 5/6 97.1% 99/102 88.9% 1 035/1 164 89.5% 1 139/1 272 254/ND 79.8% 877/1 099 68.9% 2 926/4 248 75.9% 4 057/5 347a CHINA 0.2% 3/1 954b 0.04% 3/6 850b 0% 0/7 009b 0.02% 6/25 860 81.6% 692/848 90.6% 289/319 0 84.1% 981/1 167 LAO PEOPLE'S DEM. REP. 57.1% 4/7 32.0% 49/153 0% 0/139 17.7% 53/299 69.3% 194/280 76.5% 374/489 0 73.9% 568/769 MONGOLIA 75.0% 9/12 70.8% 17/24 40.4% 23/57 52.6% 49/93 77.8% 396/509 83.1% 364/438 25.6% 140/546 60.3% 900/1 493 PAPUA NEW GUINEA 100% 1/1 58.1% 18/31 27.4% 175/639 28.9% 194/671 70.3% 135/192 579/ND ND 714/ND PHILIPPINES 87.4% 104/119 84.2% 324/385 74.1% 665/897 78.0% 1 093/1 401 41.7% 890/2 133 43.6% 786/1 801 ND 42.6% 1 676 c,d /3 934 SOLOMON ISLANDS 100% 1/1 66.7% 6/9 47.3% 138/292 48.0% 145/302 100% 122/122 41.3% 100/242 53.8% 186/346 57.5% 408/710 VIET NAM 76.9% 10/13 49.9% 677/1 356 ND/4 440 e 50.2% 687/1 369 c 55.9% 1 187/2 125 52.2% 7 426/14 229 ND 52.7% 8 613/16 354 TOTAL 6.5% 137/2 113 13.4% 1 193/8 910 13.9% 2 036/14 637 10.8%f 3 366/31 267 62.3% 3 870/6 209 58.0% 10 795/18 617 63.3% 3 252/5 140 30 251g ND: no data a. Denominator is an underestimation as there are no data available on total number of staff providing childbirth and newborn care in national/regional hospitals. b. There is a total of 25 860 health facilities in China, many of which do not provide childbirth services. Denominator for fi rst-level referral facilities may include regional facilities; 10 045 facilities in China do not have a classifi cation for level. c. Total for national, regional and fi rst-level referral hospitals only. d. A total of 14 006 health workers have been coached in the Philippines; however, a breakdown of coaching data by health facility is not available from all facilities. Data shown here by level are only for selected facilities. e. Denominator is based on the estimate that 40% of community health centres (n = 11 101) provide childbirth services in Viet Nam. f. Does not include fi rst-level facilities in Viet Nam, as data on the number of facilities where EENC has been introduced are not available. g. The total of 14 006 health workers coached in the Philippines was included here to refl ect that a total of 30 251 staff have been coached in the Region. Proportion of staff was not calculated due to incomplete data from some countries. Box 3. rapid scale-up of eenc in viet nam Viet Nam has made dramatic progress in introducing EENC. In three years, half of all national and first-level referral hospitals in the country have adopted EENC and over 8000 staff have received coaching. The expansion of EENC has been achieved by using centres of excellence, which have supported provincial coaching. "I've conducted training for 20 years, but the sessions were never as successful as EENC." – Staff member, Ministry of Health, Viet Nam • selection of centres of excellence and coaching of facilitators, July 2014 Before launching the EENC initiative, the Ministry of Health selected three hos- pitals to become Centres of Excellence: the National Hospital for Obstetrics and Gynaecology in the northern zone; Da Nang Hospital for Women and Children in the central zone; and Tu Du Hospital in the southern zone. With support from the WHO Regional Office for the Western Pacific, each hospital coached 10–12 of its own staff as facilitators. The facilitators received two days of coaching, attended a one-day orientation on facilitation, and then conducted at least one coaching session under supervision. A group of accredited facilitators was established at each of the three hospitals to lead implementation. • national policy directives, november 2014 The Early Essential Newborn Care Clinical Practice Pocket Guide, published by the WHO Regional Office for the Western Pacific, was reviewed and adapted for Viet Nam as an evidence-based national clinical protocol after extensive stakeholder consultations. In November 2014, the Ministry of Health released Decision No. 4673 that required all facility-based staff to follow the EENC protocol and EENC- related policies. This was followed by an official letter from the Ministry of Health requesting Provincial People’s Committees to ensure that departments of health guide and monitor health facilities in the implementation of Decision No. 4673. EENC implementation was also included in the criteria for evaluating the quality of hospital care (Decision No. 6858 in November 2016), which is conducted an- nually in Viet Nam. second BIENNIAL PROGRESS REPORT (2016–2017) 14 15 • coaching of staff at centres of excellence by facilitators, July–december 2014 National facilitators coached staff in their own hospitals and established EENC hospital teams. They supervised teams to conduct quarterly self-assessments of the quality of routine childbirth and newborn care and to use data to take action to improve and support EENC practices. • provincial eenc expansion plans – centres of excellence, ministry of health, provincial health departments, december 2014–onwards EENC facilitators at the Centres of Excellence developed an EENC coaching plan for provincial health staff in their own zones in collaboration with the Ministry of Health maternal and child health department. Funds to support coaching and oversight visits were provided by the Ministry of Health. Provincial health depart- ments coordinated with hospitals and helped with arrangements. Successive rounds of EENC coaching reached the majority of provincial hospitals by the end of 2017. There are 500 coaching facilitators covering all 63 provinces of the country, in addition to 160 facilitators in 80 medical schools and training facilities. • further development of the national eenc programme, 2016 and 2017 As EENC became institutionalized across hospitals in Viet Nam, the Ministry of Health introduced EENC for caesarean section deliveries and Kangaroo Mother Care (KMC) for preterm and low-birthweight babies in the Centres of Excellence and other selected hospitals. Policy Directive No. 6734 (November 2016) intro- duced guidelines on EENC for caesarean section deliveries. With support from WHO, KMC readiness assessments and KMC staff coaching were conducted in 2016. Since then, Centres of Excellence have supported this process in hospitals in their zones. second BIENNIAL PROGRESS REPORT (2016–2017) 16 routine antenatal and delivery practices Evidence-based practices before and during delivery are often not applied. Harmful or unnecessary practices such as fundal pressure and forced pushing remain com- mon, with care often provided to suit the schedules and preferences of staff rather than needs of mothers and babies. Core antenatal and childbirth practices are now incorporated into health facility EENC standards to ensure they are monitored and that action is taken to improve them. Testing for syphilis and HIV is recommended for all pregnant women as early as possible in pregnancy. Only 32% were tested for syphilis and 55% for HIV. Syphilis testing was generally lower for babies born at subnational as opposed to national facilities (Fig. 5). A partograph is a useful tool to assess the well-being of a woman and her baby and to reduce the risk of adverse birth outcomes. However, it was completed correctly for 59% of term deliveries, with higher completion rates at subnational facilities (Fig. 5). During all stages of labour, food and fl uids, mobility, assuming a position of choice, and having continuous companionship are highly recommended for women. Adop- tion of an upright position during the second stage of labour may reduce episiotomy and instrumental vaginal births. Similarly, companionship improves the birth experi- ence and may reduce the length of labour, need for caesarean section, instrument deliveries, use of pain relief and low Apgar scores among newborns at fi ve minutes. Sixty-nine per cent of women delivering term babies were encouraged to take food and fl uids during labour, 50% were offered mobility and encouraged to fi nd the most comfortable position, and 24% had a companion of choice continuously during labour and in the delivery room. More women at national facilities were offered mobility and allowed companionship (Fig. 5). Food and fl uids as needed Non-supine position during active labour Companion of choice No unnecessary episiotomy Oxytocin to mothers within 1 min of birth Respectful and quality care during childbirth improves outcomes for mother and baby o xY To cI n 17 WHO currently recommends episiotomies only for strict clinical indications because it increases rates of posterior perineal trauma, suturing and healing complications (12). Episiotomy was performed for 37% of term deliveries and was prevalent at all levels (Fig. 5). Between countries, episiotomy rates varied from 6% to 71%. The high rate of episiotomies suggests many are done for inappropriate reasons. Postpartum haemorrhage (PPH) is the leading cause of maternal mortality in low- income countries and accounts for one quarter of all maternal deaths globally. The majority of these could be avoided through the use of prophylactic oxytocin during the third stage of labour and by timely and appropriate management (13). Oxytocin was given within one minute of birth to 79% of mothers. Routine enema (25%), amniotomy (14%) and augmentation of labour (20%) remain common and are often not based on evidence-based criteria. Detailed reviews of these procedures are not included here but will be reviewed in detail as a part of Early Essential Newborn Care Module 5 – Introducing and Sustaining EENC in Hos- pitals: Managing Childbirth and Postnatal Complications. Syphilis testing recorded Encouraged to take food and fl uids Amniotomy HIV testing recorded Encouraged to be mobile and keep best position during labour Augmentation of labour Partograph completed correctly Enema Continuous companionship during labour Episiotomy Oxytocin injected ≤ 1 minute of birth figure 5. Antenatal care and delivery practices by facility level, eight countries, June 2017 National health facilities (n = 32) Subnational health facilities (n = 129) Source of data: 161 randomly selected health facilities implementing EENC across 8 countries (32 national/regional, 121 fi rst-level referral and 8 fi rst-level). Delivery practices (eating and drinking, position, companion) from interviews of 1344 postnatal mothers. Syphilis testing, HIV testing, episiotomy, enema, amniotomy and augmentation of labour from chart reviews of 1366 postnatal mothers. Timing of oxytocin injection from observations of 385 deliveries. 0 20 40 60 80 100 Pregnant women (in %) 48 25 43 59 49 61 63 71 59 47 28 22 81 78 28 40 12 28 17 13 24 19 second BIENNIAL PROGRESS REPORT (2016–2017) 18 immediate newborn care for term, preterm and lBW babies EENC is effective for reducing risks of illness and preventable mortality for term, preterm and LBW babies. Skin-to-skin (STS) contact and breastfeeding prevent hypothermia, infec- tion and death. In contrast, separation from mothers exposes newborns to these problems. Eighty-seven per cent of term babies received STS contact, 75% within one min- ute of birth, and 57% remained in sustained STS contact until completion of the first breastfeed; however, only 36% remained in uninterrupted STS contact for 90 minutes (Fig. 6). Rates of early STS contact are high across all levels of facilities, with subnational facilities generally having higher rates. Of term babies, 95% re- ceived any breastfeeding, 62% were breastfed early (within 15–90 minutes of birth) and 85% were exclusively breastfed, with 56% receiving both early and exclusive breastfeeding (Fig. 7). Ten per cent of all term babies were bottle-fed. Ninety per cent of all term babies received dry cord care and 74% were bathed 24 hours after birth. Eighty-six per cent of term babies received the hepatitis B birth dose vaccine within 24 hours of birth. Preterm and LBW babies are 19% less likely to receive immediate STS contact than term babies and 16% less likely to be exclusively breastfed. Preterm and LBW babies do not receive the same care as term babies: 67% received any STS contact, 56% within one minute of birth and 29% remained in sustained STS contact until completion of the first breastfeed; 17% remained in uninter- rupted STS contact for at least 90 minutes (Fig. 6). Of all preterm and LBW babies, 72% received any breastfeeding, 22% were breastfed early, 69% were exclusively breastfed, with 17% receiving both early and exclusive breastfeeding. Twenty-four per cent of all preterm and LBW babies were bottle-fed (Fig. 7). Observations and discussions with health staff reveal early separation of stable preterm and LBW babies is done for several reasons, which are incorrect, such as routine observation in a neonatal care unit (NCU) (Box 4). The longer babies are maintained in STS contact, the higher the rates of exclusive breastfeeding for both term and preterm and LBW babies (Fig. 8). Antenatal steroids, provided they are administered to the mother according to guidelines, are associated with reduced neonatal deaths from respiratory distress syndrome. Magnesium sulfate reduces rates of cerebral palsy (14). Only 61% of women at 24–34 weeks of gestation received corticosteroids and 35% of women 19 less than 32 weeks of gestation received magnesium sulfate (Fig. 9). In many coun- tries, related policies are not in place. Uninterrupted KMC for at least 20 hours each day prevents up to half of all deaths of preterm and LBW babies, reduces morbidity from infection, increases breastfeeding rates, provides effective thermal control and improves developmental outcomes (15). KMC was practised for 35% of preterm and LBW babies, a signifi cant improvement from 7% in 2016. Only 15% received KMC for at least 18 of the previous 24 hours (Fig. 9). Of 161 health facilities assessed for childbirth and newborn care, babies born by caesarean section were sampled in 83 hospitals. In these hospitals, 99/380 (26%) of births by caesarean section received any STS contact (Fig. 10). National caesarean section rates in the eight priority countries range from 6% to 34%. Using these estimates, 4.6 million babies each year do not receive the benefi ts of EENC.4 4. Estimate calculated from applying national caesarean section and facility delivery rates (sources: Country Demographic and Health Surveys and Multiple Indicator Cluster Surveys, 2006–2015, National Health Statistics Annual Report of China, 2016, Mongolia Health Indicators, 2015) to 2015 birth cohorts (The State of the World’s Children, UNICEF, 2016). Estimated rates of STS contact with caesarean section were then applied to the regional estimate for total caesarean section births in health facilities. figure 6. Skin-to-skin (STS) practices – term, preterm and LBW babies, eight countries, June 2017 Source of data: Interviews with postnatal mothers in 161 randomly selected health facilities implementing EENC (32 national/regional, 121 fi rst-level referral and 8 fi rst-level) for term babies, and 85/161 health facilities (28 national/regional, 57 fi rst-level referral) for preterm/LBW babies. 100 80 60 40 20 0 Al l b ab ie s (in % ) any sts contact sts contact ≤ 1 min after birth sts contact ≥ 90 minsustained sts contact until 1st breastfeed 87 75 57 36 67 56 29 17 Term babies (n = 1398) Preterm/LBW babies (n = 344) second BIENNIAL PROGRESS REPORT (2016–2017) 20 figure 7. Breastfeeding practices – term, preterm and LBW babies, eight countries, June 2017 figure 8. Percentage of babies exclusively breasfed prior to discharge by duration of skin-to-skin (STS) contact – term, preterm and LBW babies, seven countries, June 2017 Source of data: Interviews with postnatal mothers in 161 randomly selected health facilities implementing EENC (32 national/regional, 121 fi rst-level referral and eight fi rst-level) for term babies, and 85/161 health facilities (28 national/regional, 57 fi rst-level referral) for preterm/LBW babies. Source of data: Interviews with postnatal mothers in 155 randomly selected health facilities implementing EENC (29 national/regional, 118 fi rst-level referral and eight fi rst-level) for term babies, and 80/161 health facilities (26 national/regional, 54 fi rst-level referral) for preterm/LBW babies. Does not include data from China. 100 80 60 40 20 0 100 80 60 40 20 0 Al l b ab ie s (in % ) Ba bi es e xc lu si ve ly b re as fe d (in % ) Duration of STS contact (in minutes) any breastfeeding early breastfeeding (within 15–90 min of birth) 30 early and exclusive breastfeeding Bottle-feeding 90 exclusive breastfeeding 60 95 62 85 56 10 72 22 69 17 24 Term babies (n = 1398) Term babies (n = 1328) Preterm/LBW babies (n = 344) Preterm/LBW babies (n = 324) 21 figure 9. Management of preterm and LBW babies, eight countries, June 2017 Source of data: 85 randomly selected hospitals implementing EENC across eight countries. KMC practices from interviews of 344 postnatal mothers, antenatal corticosteroids for 24–34 weeks of gestation from chart reviews of 227 postnatal mothers, magnesium sulfate for < 32 weeks of gestation from chart reviews of 75 postnatal mothers. Source of data: Interviews with postnatal mothers of term babies in 83 randomly selected health facilities implementing EENC (25 national/regional, 58 fi rst-level referral). 100 80 60 40 20 0 Pr eg na nt w om en / pr et er m b ab ie s (in % ) antenatal corticosteroids 24–34 weeks of gestation magnesium sulfate < 32 weeks of gestation Kmc > 18 hany Kmc 61 35 35 15 figure 10. Term babies born by caesarean section receiving any skin-to-skin (STS) contact, eight countries, June 2017 100 80 60 40 20 0Ba bi es d el iv er ed b y ca es ar ea n se ct io n re ce iv in g an y ST S co nt ac t (in % ) camBodia china mongolia philippines viet namsolomon islands 48 52 50 40 17 31 papua neW guinea lao people's dem. rep. 0 0 second BIENNIAL PROGRESS REPORT (2016–2017) 22 environmental hygiene practices Only 39% (933/2378) of delivery, operating, NCU and postnatal care rooms across 161 health facilities had sinks with soap, running water and disposable towels (or hand dryer), and 59% (1398/2378) of all rooms had alcohol hand gel available. Only 3% of sinks (31/897) in postnatal care rooms have all supplies needed for effective handwashing, because hospitals often require patients to bring their own supplies (Fig. 11). Observations of delivery practice found that adequate hand hygiene was practised in only 66% of cases.5 Although not formally measured, hospital obser- vations and reports from staff members indicate that use of cell phones by both staff and patients in facilities is common, with limited washing of hands after using phones and touching newborns. Hand hygiene is a major problem in the Region. 5. Adequate hand hygiene comprises washing hands twice, the fi rst before setting up the delivery area and the second before putting on sterile gloves for delivery, and then using sterile gloves prior to cutting the umbilical cord. figure 11. Handwashing facilities by room type in 155 health facilities, seven countries, June 2017 100 80 60 40 20 0 Si nk s (in % ) clean sinks have running water have single use towels/hand dryers have running water, soap and single use towels/hand dryers have soap 89 94 87 55 90 94 93 62 92 93 74 19 34 33 3 16 96 96 78 57 Delivery rooms (n = 447 sinks) Recovery rooms (n = 172 sinks) Postnatal care rooms (n = 897 sinks) Neonatal care unit (n = 355 sinks) Source of data: Observations of environmental hygiene in 155 randomly selected health facilities implementing EENC (29 national/ regional, 118 fi rst-level referral and eight fi rst-level). Does not include data from China. 23 essential medicines and commodities Essential medicines and commodities were generally available in facilities, with stock- outs rarely a problem for most medicines (Annex 5). Stock-outs were reported most commonly for antenatal corticosteroids. Oxytocin was generally available, but in several facilities was stored at room temperature, not at 2–8 °C as recommended. Continuous positive airway pressure (CPAP) machines were often not available at first-level referral hospitals. Ambu bags and masks were available and functional in 81% (438/541) of resuscitation areas across 161 health facilities, and newborn resuscitation areas were within two metres of delivery beds – as recommended by EENC standards – in 81% (131/161) of facilities. second BIENNIAL PROGRESS REPORT (2016–2017) Box 4. separation of mothers and babies: a habit that must be broken Early separation of mothers and their babies remains common, especially for pre- term and lBW babies and those born by caesarean section. • Why is early separation harmful? Early separation increases the risks of hypothermia, infection and death and limits other benefits of STS contact including early and exclusive breastfeeding. Admis- sion to neonatal care units compounds these risks. Approximately 85% of preterm infants are 32–36 weeks of age and do not require highly specialized care. • Why are preterm and lBW babies who are otherwise stable separated? » Incorrect policies and patient management protocols that require all preterm and LBW babies and those born by caesarean section to be routinely admitted to NCUs for observation and procedures. » Incorrect staff perceptions that routine tasks must be done immediately, that small babies need specialized care in a NCU, and that the mother is not capable of supporting her baby. » Financial incentives to provide highly specialized care (conflicts of interest) » Lack of staff to support and monitor babies kept with their mothers • What can be done to reduce early separation? » All babies – Modify delivery room protocols, better educate staff and reorgan- ize work environments to allow delayed routine tasks, with commitment of delivery room managers and senior staff. » Preterm and LBW babies – Restrict NCU admission policies, reorganize postnatal care rooms to allow prolonged STS contact, coach staff and allocate space and resources for KMC, and monitor progress. » Caesarean section deliveries – Develop a clear protocol for EENC with caesarean section, and coach all operative and recovery room staff, including anaesthesiolo- gists, obstetricians and nurses. Allocate additional staff to assist with positioning and support of the baby in the STS position. 24 25 tracking hospital impact 4 While hospital impact data should be able to help in clinical decision-making, help identify outbreaks and track long-term trends, only 6% of national/regional and first-level referral hospitals that have introduced EENC (n = 80) reported any of the nine hospital impact indicators. Of those reporting hospitals, complete data were available for 71% and partial data for 12% of indicators. Ninety-eight per cent of hospital impact indicators for which data were available, or partially available, were validated (Table A3.3 in Annex 3). Large-scale collection of hospital data has not been possible in any country except Mongolia, which has integrated hospital impact data into the routine MCH surveil- lance system. Cambodia has integrated five EENC indicators into a web-based health management information system (HMIS), although data quality issues remain. Hospital data reviews and anecdotal reports from staff reveal that problems with hospital data collection are common in all countries. Case definitions for live births, neonatal deaths and stillbirths may not match international standards; case definitions of neonatal sepsis and asphyxia are often different within and between countries. In some settings, babies in the NCU are discharged when very sick or likely to die and therefore are never registered as deaths. Case registers are often incomplete and inaccurate. For this reason, assessments of hospital routine reporting systems to identify gaps and problems are recommended so that action can be tailored to local needs. A rapid assessment method, using simple tools to identify data gaps and actions to address these gaps, has been developed and used in Cambodia and Mongolia. This method validates reported EENC hospital indicators by conducting a register review and interviewing staff who collect and use data. The assessment in Mongolia found high accuracy in transfer of EENC hospital impact indicators from patient charts to an electronic database. Only for indicators of preterm births and deaths was under- or over-reporting noted due to incorrect definitions of preterms. In Cambodia, consistent under- or over-reporting of several EENC indicators was found. This was attributed to several factors, namely paper-based systems that are prone to errors in data transfer, incomplete recording in registers, and incorrect second BIENNIAL PROGRESS REPORT (2016–2017) 26 indicator definitions. Neonatal deaths were undercounted by 95% in the HMIS for the period assessed because deaths in paediatric wards were not counted in the database. Other factors likely to influence data quality are the use of multiple recording sources, lack of formal tally sheets, and insufficient feedback to hospitals on data reported that would help identify strengths and areas for improvement on data quality. Findings were discussed by staff at all levels of the system and feasible solutions to problems developed. This approach has value for all countries collecting EENC hospital data to help im- prove data quality and completeness. 27 population coverage Improving population coverage of EENC interventions is the primary outcome of the EENC programme and a result of effective policy and systems inputs. No new data were available since 2015 for four countries, with three countries (China, Mongolia and Viet Nam) adding updates from routine HMIS data, and Solomon Islands from a Demographic and Health Survey (DHS) (Annex 4). Thirteen indicators are reported to track population-based coverage. All eight coun- tries reported on the coverage indicators, with data available for 67% of indicators. Ninety-one per cent of available data were validated (Table A 3.4 in Annex 3). Coverage data were least often available from countries that have not conducted large-sample, population-based surveys regularly. Indicators most frequently reported were skilled birth attendance, facility delivery rates, caesarean section rates, and mothers receiving postnatal care within two days of birth. Indicators least frequently reported were newborn care practices. The review highlighted three main points about population coverage. First, reliable measures of immediate newborn care practice, important for validating national progress, have not been included in population-based surveys, such as DHS or Mul- tiple Indicator Cluster Survey (MICS) with the exception of the 2013 Philippines DHS that included an indicator on early STS contact. Incorporating these indicators into such surveys will require programme managers and planners to actively participate in the development of survey questionnaires. Second, the review again noted the high rates of deliveries by skilled attendants and at facilities in most priority countries. High coverage levels (Fig. A 4.1 in Annex 4) mean that improving the quality of care remains a key priority for further reduc- tions in maternal and newborn deaths and illness. In particular, increasing rates of facility delivery mean that caesarean section deliveries are likely to further increase. Population coverage data show very high national caesarean section rates in three priority countries (Fig. A 4.1 in Annex 4), particularly in urban areas. While data eenc intervention coverage and population impact 5 second BIENNIAL PROGRESS REPORT (2016–2017) 28 are not available on the proportion of unnecessary caesarean sections in countries with high rates, caesarean section rates higher than 10% are not associated with reductions in maternal and newborn mortality (16). Eliminating procedures conducted for non-medical reasons and ensuring babies born by caesarean section also benefit from EENC are critical in the next two years. Third, national coverage rates mask important inequities associated with wealth and educational status, urban/rural residence and other factors that remain common in most countries (17). For example, although caesarean section rates in Cambodia are 6.3% nationally, rates among provinces range from 2% to 14% (18). Similarly, in the Lao People’s Democratic Republic, with a national caesarean section rate of 4%, rates among provinces range from 0.5% to 15% (19). Location of high-risk populations may influence areas to target for early implementation and scale-up of EENC. Unnecessary procedures, a growing problem with increased facility delivery rates, will need to be better understood and evidence-based criteria more widely adopted. impact indicators for newborn health Five indicators tracking newborn health impact were reported by all eight countries. Data on preterm birth rates using modelled estimates were added where data were not reported in 2015 (20). China, Mongolia and Viet Nam updated impact data using routine health information statistics and Solomon Islands did so using 2015 DHS data. Sources of impact data included the United Nations Inter-agency Group for Child Mortality Estimation (IGME) (for neonatal mortality estimates and causes of death), population-based surveys, and routine surveillance data in countries with relatively high system coverage and reporting (China and Mongolia). Eighty-five per cent of impact indicators for newborn health were reported by countries. Data were most frequently unavailable for perinatal mortality (Table 2). Ninety-four per cent of available data were validated (Table A 3.5 in Annex 3). All countries collect mortality and birthweight data and use these data for track- ing progress. Findings were similar to those in 2015. The review re-emphasized three important conclusions based on findings. First, preterm birth rates should be included in population-based surveys or routine data systems. Second, countries should prioritize improving the collection of newborn data using routine HMIS. Current challenges with routine information systems include under-registration and under-reporting of live births, neonatal deaths and stillbirths (number and 29 causes), no routine reporting of neonatal deaths separate from child deaths, and non-application of globally recommended standard case definitions for many in- dicators. HMIS data are currently used for tracking newborn health impact data in two countries (China, Mongolia), although the accuracy and precision of these data have not been validated. taBle 2. Population impact indicators, eight countries, February 2018 CAMBODIA CHINA LAO PEOPLE'S DEM. REP. MONGOLIA PAPUA NEW GUINEA PHILIPPINES SOLOMON ISLANDS VIET NAM Neonatal mortality rate (per 1000 live births) 18.0 5.4 29.0 10.2 24.0 13.0 9.0 12.0 Perinatal mortality rate (per 1000 live births) 20.0 4.9 No data 14.6 No data 22.0 14.0 No data Proportional causes of neonatal death – sepsis – tetanus – birth asphyxia – preterm birth – congenital anomalies 16.7% 0.3% 23.1% 31.1% 15.5% 2.6% 0.0% 25.5% 30.8% 15.2% 16.3% 1.2% 28.7% 28.2% 9.7% 2.8% 0.0% 7.5% No data 9.6% 16.0% 0.9% 27.5% 30.0% 11.0% 13.4% 0.3% 23.9% 31.0% 16.8% 14.8% 0.3% 23.1% 31.2% 18.0% 8.6% 0.6% 13.5% 40.4% 22.7% Low-birthweight rate (< 2500 g) 7.9% 2.6% 14.8% No data No data 21.4% 10.2% 6.8% Preterm-birth rate (< 37 weeks) 10.5% 7.8% 10.8% 13.5% 6.5% 14.9% 12.4% 9.4% Source of data: Data from country Demographic and Health Surveys and Multiple Indicator Cluster Surveys, 2006–2015. For China and Mongolia, data are from routine health information systems. Neonatal mortality estimates are from IGME for countries where surveys were not conducted in the past three years. Data on proportional causes of death are from 2018 WHO-Maternal Child Epidemiology Estimations for the year 2016. Estimates on preterm birth rates are from national, regional, and worldwide estimates of preterm birth rates in the year 2010 with time trends since 1990 for selected countries: a systematic analysis and implications (Blencowe et al., 2012). For Viet Nam, the preterm birth rate estimate is from the 2016 National Reproductive Health Annual Report. 30 31 At the Western Pacific High-level Forum on Accelerating Progress in Early Essential Newborn Care, held in Da Nang, Viet Nam (16–17 August 2017), high-level rep- resentatives agreed on areas for improvement that must be further addressed to accelerate progress towards adoption of EENC (1) (Annex 6). continued high-level support and advocacy is needed to consolidate gains All country representatives reiterated their readiness to continue to promote EENC through improved laws, regulations, decrees and updated clinical protocols. They agreed on the urgent need to improve use of EENC for preterm and LBW babies and those born by caesarean section. They committed to reducing unnecessary over- medicalization of care for women and babies and to reducing conflicts of interest that are often behind these practices. communication will accelerate demand and supply There was widespread recognition that improved communication is essential for both improving the demand for EENC from mothers and families, and for providing information to health workers and policy-makers. At the meeting, two new videos – an EENC documentary and another on the use of EENC with caesarean section were released. Within a few days, more than 230 000 people viewed and 2200 shared the EENC documentary on Facebook, highlighting intense demand for informa- tion and visual material. A rich dialogue emerged in which respondents answered each other’s concerns, shared WHO information and called on their physicians to ensure the First Embrace is practised at every birth. The press conference held on the final day of the high-level forum attracted considerable interest, and resulted in 35 articles and four television broadcast stories, with journalists also attending the Da Nang Hospital for Women and Children tour and seeing KMC practised up close. accelerating progress towards universal adoption of eenc 6 second BIENNIAL PROGRESS REPORT (2016–2017) 32 "KMC is so simple, it is revolutionary. I’m taking this back to my country.” – Undersecretary, Ministry of Health and Medical Services, Solomon Islands. improved collaboration between obstetrics, midwifery and paediatrics remains important Bridging traditional divisions between obstetric and newborn care around delivery remains critical for extending care to all babies. This is particularly important for extending EENC to caesarean section deliveries and the management of preterm babies. Study tours to various countries demonstrating successful approaches, the production and use of educational videos and documentaries, and the publication of papers on scaling up EENC in peer-reviewed journals may all be useful for engag- ing various stakeholders – in addition to ongoing policy and programme activities in countries. 33 During the Second Biennial Meeting on Accelerating Progress in Early Essential Newborn Care in Da Nang, Viet Nam, on 14–17 August 2017, representatives from the eight priority countries discussed the status of EENC implementation, and identi- fied challenges and priority actions for the next two years (see country road maps in the full report of the meeting) (21). There was consensus across all countries that priority actions need to focus on six main areas (Table 3). The emphasis placed on each action will vary according to the current status of EENC implementation and systems capacity in the next two years. taBle 3. Priority actions developed by eight countries: consolidating gains and further scaling up EENC in the next biennium strengthen laws, regulations, policies, guidelines and advocacy PURPOSE: Ensure evidence-based standards are applied widely and sustained PR IO RI TI ES – Evidence-based routine delivery practices and respectful care – EENC with caesarean sections – Elimination of unnecessary caesarean sections – National KMC guidelines – EENC practices incorporated into pre-service curricula for medicine, nursing, midwifery – EENC/KMC practices included in service packages reimbursed by health insurance continue to scale up eenc coaching PURPOSE: Complete coaching for all obstetrics, midwifery and paediatric staff PR IO RI TI ES – Develop plans to expand and maintain quality of EENC clinical coaching – Ensure coaching meets standards – 6:1 participant-to-facilitator ratio; two days full-time – Train more accredited facilitators to support expansion – Consider establishing centres of excellence to coordinate and support EENC coaching priority actions to consolidate gains and further scale up eenc in the next biennium 7 second BIENNIAL PROGRESS REPORT (2016–2017) 34 introduce Kmc for preterm and lBW babies and eenc for caesarean section deliveries PURPOSE: Improve care of babies who currently do not receive the benefits of EENC PR IO RI TI ES – Coach facilitators in KMC and EENC with caesarean section – Develop scale-up plan for phased introduction at provincial hospitals or higher – Begin KMC in hospitals where most staff have been coached and are practicing EENC improve systems to maintain quality of eenc clinical practices PURPOSE: Modify systems to support and encourage EENC evidence-based practices at all deliveries PR IO RI TI ES – Establish EENC teams to oversee EENC implementation and monitor quality of care – Ensure regular self-assessments of quality of care and planning by EENC hospital teams – Prioritize organization of work to allow 90 minutes of skin-to-skin contact, early and exclusive breastfeeding – Address barriers to improve hand hygiene urgently – Include EENC/KMC practices in hospital accreditation standards – Ensure regular collection of data for tracking progress using the EENC Monitoring and Evaluation Framework 35 1. The Chair’s Statement of the High-Level Forum for Accelerating Progress in EENC in Report of the Meeting on Accelerating Progress in Early Essential Newborn Care, 14–17 August 2017, Da Nang, Viet Nam. Manila, World Health Organiza- tion; October 2017. 2. Levels and trends in child mortality – Report 2017. New York, UNICEF; 2017 (es- timates for 2016). 3. World Health Organization Regional Office for the Western Pacific, UNICEF. Ac- tion plan for healthy newborn infants in the Western Pacific Region (2014–2020). Manila, World Health Organization; 2014. 4. Progress Reports on Technical Programmes, 64th Session of the Regional Com- mittee, Manila, Philippines, 21–25 October 2013. WPR/RC64/9. Manila, World Health Organization; 2013. 5. World Health Organization Regional Office for the Western Pacific. Coaching for the First Embrace: facilitator’s guide. Early Essential Newborn Care (EENC) Module 2. Manila, World Health Organization; 2016. 6. World Health Organization Regional Office for the Western Pacific. Introducing and sustaining EENC in hospitals: routine childbirth and newborn care. Early Es- sential Newborn Care (EENC) Module 3. Manila, World Health Organization; 2016. 7. World Health Organization Regional Office for the Western Pacific. Introducing and sustaining EENC in hospitals: Kangaroo Mother Care for preterm and low birth weight infants. Early Essential Newborn Care (EENC) Module 4. Draft. Ma- nila, World Health Organization; August 2017. 8. World Health Organization Regional Office for the Western Pacific. Annual im- plementation review and planning guide. Early Essential Newborn Care (EENC) Module 1. Manila, World Health Organization; 2018. 9. World Health Organization Regional Office for the Western Pacific, Meeting on Accelerating Progress with EENC, Tokyo, Japan, 21–25 September 2015. Manila, World Health Organization; 2016. WPR/DNH/MCA(02)/2015. 10. World Health Organization Regional Office for the Western Pacific. First biennial progress report: action plan for healthy newborn infants in the Western Pacific Region (2014–2020). Manila, World Health Organization; 2016. references second BIENNIAL PROGRESS REPORT (2016–2017) 36 11. World Health Organization Regional Office for the Western Pacific. Early Essential Newborn Care: clinical practice pocket guide. Manila, World Health Organiza- tion; 2014. 12. Carroli G, Mignini L. Episiotomy for vaginal birth. Cochrane Database Syst Rev 2009. CD000081. doi: http://dx.doi.org/10.1002/14651858.CD000081.pub2 PMID:19160176 13. World Health Organization. Recommendations for the prevention and treatment of post-partum haemorrhage. Geneva, World Health Organization; 2012. 14. World Health Organization. Recommendations on interventions to improve pre- term birth outcomes. Geneva, World Health Organization; 2015. 15. Conde-Agudelo A, Díaz-Rossello JL. Kangaroo mother care to reduce morbidity and mortality in low birthweight infants. Cochrane Database of Systematic Reviews 2016, Issue 8. Art. No.: CD002771. DOI: 10.1002/14651858.CD002771.pub4. 16. World Health Organization. WHO Statement on Caesarean Section Rates. Geneva, World Health Organization; 2015. Available at: http://www.who.int/reproduc- tivehealth/publications/maternal_perinatal_health/cs-statement/en/ 17. Barros AJ, Ronsmans C, Axelson H, Loaiza E, Bertoldi AD, Franca GV et al. Equity in maternal, newborn, and child health interventions in Countdown to 2015: a retro- spective review of survey data from 54 countries. Lancet 2012;379(9822):1225–33. 18. National Institute of Statistics/Cambodia, Directorate General for Health/Cam- bodia, and ICF International. Cambodia Demographic and Health Survey 2014. Phnom Penh, Cambodia, National Institute of Statistics/Cambodia, Directorate General for Health/Cambodia, and ICF International; 2015. Available at: http:// dhsprogram.com/pubs/pdf/ FR312/FR312.pdf 19. Ministry of Health, Lao PDR and Lao Statistics Bureau (LSB). Lao Social Indicator Survey 2011–12. Vientiane, Lao PDR; 2012. Available at: https://dhsprogram.com/ pubs/pdf/FR268/FR268.pdf 20. Blencowe H, Cousens S, Oestergaard MZ et al. National, regional, and worldwide estimates of preterm birth rates in the year 2010 with time trends since 1990 for se- lected countries: a systematic analysis and implications. Lancet 2012;379:2162–72 21. Report of the meeting on Accelerating Progress in Early Essential Newborn Care, 14–17 August 2017, Da Nang, Viet Nam. Manila, World Health Organization; October 2017. annexes annex 1. early essential newborn care (eenc) Table A 1.1 Detailed EENC interventions for all and high-risk mothers and newborn infants annex 2. eenc monitoring and evaluation framework (2015–2020) Table A 2.1 Benchmarks of EENC scale-up readiness Table A 2.2 Health facility EENC standards Table A 2.3 Hospital impact indicators Table A 2.4 Coverage indicators for EENC Interventions Table A 2.5 Impact indicators for newborn health annex 3. validation of eenc monitoring and evaluation data from eight priority countries Table A 3.1 Summary of the availability of data on EENC scale-up readiness benchmarks and validation status by country, June 2017 Table A 3.2 Summary of the availability of data on EENC facility standards and validation status by country, June 2017 Table A 3.3 Summary of the availability of data on EENC hospital impact indicators and validation status by country, June 2017 Table A 3.4 Summary of the availability of data on population coverage indicators and validation status by country, June 2017 Table A 3.5 Summary of the availability of data on impact indicators and validation status by country, June 2017 annex 4. eenc population coverage indicators Figure A 4.1 Population coverage for skilled birth attendance, facility delivery and caesarean section, eight countries, 2006–2016 Figure A 4.2 Population coverage for prelacteal feeding, early breastfeeding and exclusive breastfeeding from 0 to 1 month, eight countries, 2006–2016 Figure A 4.3 Population coverage for maternal and newborn postnatal care, eight countries, 2006–2016 annex 5. eenc country profiles annex 6. chair’s statement of the high-level forum on accelerating progress in early essential newborn care 37 38 annex 1 early essential newborn care (eenc) Early Essential Newborn Care (EENC) is the central pillar of the regional approach to preventing neonatal mortality. It is a package of evidence-based interventions dem- onstrated to reduce mortality from the three most important causes: prematurity, birth asphyxia and sepsis. The EENC approach consists of: • The First Embrace • Prevention and care of preterm (< 37 weeks) and low-birthweight (< 2500 g) babies • Prevention and care of sick newborn infants Because the greatest risk of death and adverse outcomes comes during childbirth and in the first 24 hours of life, EENC emphasizes improving the quality of childbirth and the quality of newborn and postnatal care in the first 24 hours after birth. EENC focuses on eliminating harmful and outdated practices, including unnecessary proce- dures and admissions to neonatal care units, and replacing them with evidence-based practices. Improving practices during delivery and the immediate postpartum period improves outcomes for both mothers and babies. EENC is implemented through exist- ing services and helps to identify health systems gaps that need to be strengthened. core interventions of early essential newborn care INTRAPARTUM CARE NEWBORN CARE all mothers and newborn infants 1. The First Embrace Labour monitoring (partograph) • Immediate drying • Immediate skin-to-skin contact • Appropriately timed clamping and cutting of the cord • Exclusive breastfeeding • Routine care – eye care, vitamin K, immunizations, weighing and examination at-risk mothers and newborn infants 2. Preterm and low- birthweight infants • Preterm labour – Elimination of unnecessary inductions and caesarean sections – Antenatal steroids – Antibiotics for preterm PROM • Kangaroo Mother Care • Breastfeeding support • Immediate treatment of suspected infection 3. Sick newborn infants • Obstructed/prolonged labour • Fetal distress: – Assisted delivery – Caesarean section • Not breathing at birth: resuscitation • Suspected sepsis: antibiotic treatment 39 all mothers and neWBorn infants 1. the first emBrace all mothers – Maintain a supportive environment (e.g. companion and position of choice, elimination of unnecessary/ harmful procedures) – Avoid environmental exposure to cold, draughts and infection – Maternal and fetal monitoring during labour including use of the partograph – Improved recognition of labour signs, care and referral of woman with risk factors (e.g. hypertension, diabetes, preterm labour) and management of obstetric complications, especially pre-eclampsia/eclampsia – Set up newborn resuscitation area, including checking equipment for functionality – Organize delivery space – Postnatal care visits to include counselling for routine newborn care and danger signs – HIV and syphilis point-of-care rapid testing all newborn infants – Immediate and thorough drying – Delayed bathing – Immediate skin-to-skin contact all newborn infants, if breathing – Appropriately timed cord clamping, cut once – Exclusive breastfeeding when feeding cues occur – Rooming in/keeping warm – Routine care (e.g. eye care, vitamin K, immunizations and examinations) delayed until after a full breastfeed – Elimination of harmful practices including routine suctioning, placing substances on the cord stump, and prelacteal feeds – Postnatal care visits all mothers and newborn infants – Avoidance of exposure to nosocomial pathogens through: » hand hygiene and other infection prevention measures » non-separation unless urgent care required taBle a 1.1 Detailed EENC interventions for all and high-risk mothers and newborn infants eenc interventions second BIENNIAL PROGRESS REPORT (2016–2017) 40 taBle a 1.1 Detailed EENC interventions for all and high-risk mothers and newborn infants (continued) high-risK mothers and neWBorn infants 2. prevention and care of preterm and lBW neWBorn infants high-risk mothers and newborn infants – Elimination of unnecessary induction of labour and caesarean sections – Antenatal steroids (and tocolytics 1) – Antibiotics 2 for preterm pre-labour rupture of membranes – Kangaroo Mother Care – Feeding with breast milk – Monitoring for complications 3. prevention and care of sicK neWBorn infants newborn infants who are not breathing despite thorough drying (asphyxia) – Bag and mask ventilation – Post-resuscitation care (including aseptic cord trimming), monitoring and referral of cases with incomplete recovery/severe conditions sick newborn infants and newborn infants with complications of birth – Standard case management of newborn sepsis and other newborn problems (e.g. pneumonia, meningitis, other infections, jaundice, malformations) – Identification of at-risk newborn infants – Stabilization (including prevention of hypothermia, hypoglycaemia, hypoxaemia, apnoea and infection) prior to timely referral – Oxygen and/or continuous positive airway pressure (CPAP) for those with respiratory distress – Care of seriously ill newborn infants – Antiretrovirals for infants exposed to HIV and penicillin for those exposed to syphilis – Referral between levels of care and wards 1. As of 2015, tocolytics for inhibiting preterm labour are no longer recommended by WHO. Corticosteroids and magnesium sulfate are now recommended. 2. Erythromycin is recommended as the antibiotic of choice, use of a combination of amoxicillin and clavulanic is not recommended (WHO 2015 recommendations on interventions to improve preterm birth outcomes). 41 annex 2 eenc monitoring and evaluation framework (2015–2020) taBle a 2.1 Benchmarks of EENC scale-up readiness Review benchmarks annually to track progress with benchmarks scoring "No" or "Partial" and to ensure that benchmarks that previously scored "Yes" have not changed. Benchmarks Yes, No, Partial or No Data status by year target 2015 2016 2017 2018 2019 2020 1. Newborn health situation analysis conducted in the previous five years used for strategic planning1 YES 2. Five-year EENC action plan developed based on Regional Action Plan for Healthy Newborns,2 costed and adopted by the Ministry of Health YES 3. EENC annual implementation review conducted at least biennially to inform development of annual implementation plans 3 YES 4. Detailed annual EENC Implementation Plan funded YES 5. EENC technical working/coordination group meets regularly 4 YES 6. Full-time EENC/newborn health focal person appointed in the Ministry of Health YES 7. EENC stakeholder group meets regularly 5 YES 8. Clinical Intra-Partum and Newborn Care Protocol endorsed 6 YES 9. Mechanisms established to ensure that professional associations are supporting implementation of EENC YES 10. Proportion of EENC interventions (normal and high-risk deliveries) included in pre-service training curricula: a) medical; b) nursing; c) midwifery 7 100% for all second BIENNIAL PROGRESS REPORT (2016–2017) 42 1. Situation analysis includes: review of trends in newborn, child and maternal morbidity and mortality and intervention coverage along the continuum of care; an analysis of newborn health equity for different populations and groups; and status of key systems inputs to support delivery of newborn health interventions. 2. World Health Organization Regional Office for the Western Pacific, UNICEF. Action Plan for Healthy Newborn Infants in the Western Pacific Region (2014–2020). Manila, World Health Organization; 2014. 3. World Health Organization Regional Office for the Western Pacific. Annual implementation review and planning guide. Early Essential Newborn Care Module 1. Manila, World Health Organization; 2018. 4. Membership may include: ministry of health public health divisions, obstetric and paediatric decision-makers, professional associations, civil society organizations and development partners. Quarterly meetings are recommended. 5. Membership may include: policy-makers, legislators, health providers, hospital administrators, civil society leaders, develop- ment partners, media practitioners, academia and health professional associations. Quarterly meetings are recommended. 6. Most countries adapt and use the Early Essential Newborn Care: Clinical Practice Pocket Guide developed by the WHO Regional Office for the Western Pacific, 2014. 7. Technical content consistent with international EENC standards – curricula include clinical EENC coaching as part of the teaching method. EENC core interventions are described in Annex 1. 43 taBle a 2.2 Health facility EENC standards Use hospital summary forms to complete one table for all facilities of each level: (a) national and regional hospitals; (b) first-level referral hospitals; and (c) first-level where deliveries take place.1 Note indicators where findings differ between different levels of facilities. Combine summary data for term and preterm babies for all practice measures. level of facility: ___________________________ indicator data by year target 2015 2016 2017 2018 2019 2020 1. Proportion of staff providing childbirth, newborn and postpartum care services that are coached in EENC 90% 2. Proportion of facilities using a quality improvement approach to support implementation of EENC 90% 3. Pregnant women of 24–34 weeks of gestation at risk of imminent preterm birth and with no clinical evidence of infection administered the full course of intramuscular dexamethasone or betamethasone prior to childbirth 90% 4. Proportion of women receiving all key delivery care tasks: 4.a – 4.d all 90% a. Companion of choice 90% b. Non-supine position during second stage 90% c. Food and fluids 90% d. No fundal pressure 90% 5. Proportion of mothers with a correctly completed partograph 90% 6. Proportion of breathing newborns that receive: a. Immediate skin-to-skin contact 90% b. Early and exclusive breastfeeding in the immediate newborn period 90% c. Immediate and sustained skin-to-skin contact for at least 90 min and a complete breastfeed 80% 7. Proportion of newborns with a birthweight ≤ 2000 g who in the previous 24 hours received: a. Any Kangaroo Mother Care 80% b. Continuous Kangaroo Mother Care for at least 20 h 50% 8. Proportion of women who receive breastfeeding counselling in the immediate newborn period 100% 9. Proportion of delivery room(s), operation room(s), neonatal care unit(s) (NCUs), and postnatal care room(s) that have adequate handwashing resources 100% second BIENNIAL PROGRESS REPORT (2016–2017) 44 indicator data by year target 2015 2016 2017 2018 2019 2020 10. Proportion of health facilities with no stock-outs of key life-saving medicines required to provide EENC 100% (10.a –10.d all 100%) a. Magnesium sulfate for severe pre-eclampsia and eclampsia, and fetal neuroprotection if gestational age < 32 weeks 100% b. Oxytocin for the prevention and control of postpartum haemorrhage for all births 100% c. Corticosteroids for women at 24–34 weeks of gestation at risk of preterm delivery 100% d. Injectable antibiotics for management of newborn sepsis 100% 11. Proportion of health facilities with functional key life-saving commodities required to provide EENC 100% (11.a –11.c all 100%) a. Functional newborn ambu bag and preterm and term masks (sizes 0 and 1) within 2 m of each delivery bed 100% b. Continuous supply of oxygen for newborn use (national, regional and first-level referral hospitals) 100% c. Continuous positive airway pressure (CPAP) (national, regional and first-level referral hospitals) 100% 12. Proportion of health facilities that have eliminated baby-food industry conflicts of interest 100% (12.a –12.c all 100%) a. Health facilities where no mother has products or gifts from baby-food companies 100% b. Health facilities with a written policy to prohibit use of infant formula and other baby-food company activities 100% c. Health facilities with no promotional baby-food materials including posters, brochures, pamphlets or items with logos on their premises 100% 13. Proportion of EENC health facility standards (1–12) achieved 70% 1. a) National- and regional-level facilities: offer services of first-level referral plus advanced neonatal care including CPAP; serve as teaching hospitals and provide support to lower-level facilities. b) First-level referral facilities: offer services of first level plus management of preterm labour and common complications of prematurity (e.g. oxygen), advanced resuscitation, complications of delivery including assisted delivery and caesarean sections. c) First-level facilities: where deliveries take place, should have the capacity for care of breathing and non-breathing babies. taBle a 2.2 Health facility EENC standards (continued) 45 taBle a 2.3 Hospital impact indicators Use routine health management information system (HMIS) data or register reviews from hospitals that have begun implementing EENC to complete one table for each level of facility: a) national and regional hospitals; and b) first-level referral hospitals 1 for national estimates. level of facility: ____________________________ indicator data by year target 2015 2016 2017 2018 2019 2020 3.1 Neonatal care unit/nursery admission rate 3.2 Proportion of newborns by weight: 3.2.1 < 1000 g 3.2.2 1000–1499 g 3.2.3 1500–1999 g 3.2.4 2000–2499 g 3.2.5 ≥ 2500 g 3.3 Proportion of newborns born at the facility classified with newborn sepsis 2 3.4 Proportion of newborns born at the facility classified with birth asphyxia 3 3.5 Newborn mortality rate stratified by weight: 3.5.1 < 1000 g 3.5.2 1000–1499 g 3.5.3 1500–1999 g 3.5.4 2000–2499 g 3.5.5 ≥ 2500 g 3.6 Case-fatality rate (% registered cases dying): 3.6.1 Preterm 4 newborns 3.6.2 Low-birthweight newborns 5 3.6.3 Newborn sepsis 3.6.4 Newborn asphyxia 1. a) National and regional facilities: offer services of first-level referral plus advanced neonatal care including CPAP; serve as a teaching hospitals and provide support to lower-level facilities. b) First-level referral facilities: offer services of first level plus management of preterm labour and common complications of prematurity (e.g. oxygen), advanced resuscitation, complications of delivery including assisted delivery and caesarean sections. 2. Bacterial sepsis of the newborn: ICD-10 P36 (codes P36.0–P36.9, sepsis of known cause or unknown cause). 3. Birth asphyxia is defined as newborns who are gasping or not breathing at one minute of age. 4. Preterm newborns are live births less than 37 completed weeks gestation (ICD-10 P07.2 and ICD-10 P07.3). 5. Low birthweight is defined as a birthweight of < 2500 g. second BIENNIAL PROGRESS REPORT (2016–2017) 46 taBle a 2.4 Coverage indicators for EENC interventions Use representative population-based surveys – Demographic and Health Survey (DHS) and Mul- tiple Indicator Cluster Survey (MICS) or other population-based surveys – to periodically measure coverage, and HMIS and health-facility assessment data to track trends in coverage between surveys. Data are disaggregated by administrative or geographic divisions for subnational track- ing and programme planning.1 national or subnational area: ____________________ coverage measure data by year (specify source) target 2015 2016 2017 2018 2019 2020 4.1 % of live births attended by skilled health personnel 90% 4.2 % of live births that take place at health facilities 90% 4.3 % of live births delivered by caesarean section 4.4 % of live rural births delivered by caesarean section 4.5 % of newborns dried after birth 100% 4.6 % of newborns with delayed bath after birth 2 100% 4.7 % of newborns placed on the mother’s bare abdomen or chest immediately after delivery (skin-to-skin) 100% 4.8 % of newborns breastfed within one hour of birth 3 100% 4.9 % of newborns receiving a prelacteal feed 0% 4.10 % of live births with a reported birth weight 100% 4.11 % of women receiving postnatal care within two days of birth 100% 4.12 % of newborns receiving postnatal care within two days of birth 100% 4.13 % of newborns 0–1 month who are exclusively breastfed 100% 1. For survey methods and standard definitions of coverage indicators, see: http://www.dhsprogram.com/data/ Data-Tools-and- Manuals.cfm and http://mics.unicef.org. 2. Delayed bathing: at least 24 hours after birth. 3. The standard population-based survey indicator currently measures breastfeeding within 1 hour of birth and not the wider 90-minute window during which breastfeeding can occur. 47 taBle a 2.5 Impact indicators for newborn health Use large sample population-based surveys (DHS, MICS, or other large sample surveys) in most settings and civil registration and vital statistics (CRVS) data where available, valid and reliable. Modelled mortality data [United Nations Inter-agency Group for Child Mortality Estimation (IGME) and Child Health Epidemiology Reference Group (CHERG)] may be used to track trends. Data are disaggregated by country administrative or geographic divisions for subnational track- ing and programme planning.1 national or subnational area: ____________________ population impact indicators data by year (specify source) target 2015 2016 2017 2018 2019 2020 5.1 Neonatal mortality rate (per 1000 live births) 10 5.2 Stillbirth rate 2 (per 1000 births) 5.3 Perinatal mortality rate 3 (per 1000 live births) 5.4 Proportional causes of neonatal death: 5.4.1 Sepsis 5.4.2 Tetanus 5.4.3 Birth asphyxia 5.4.4 Preterm birth 5.4.5 Congenital anomalies 5.5 Low-birthweight rate (< 2500 g) 5.6 Preterm birth rate (< 37 weeks) 1. For survey methods and standard definitions of impact indicators, see: http://www.dhsprogram.com/data/Data-Tools-and- Manuals.cfm and http://mics.unicef.org. 2. For international comparisons and reporting, WHO/ICD defines stillbirths as the death of a fetus that has reached a birthweight of ≥ 1000 g, or if birthweight is unavailable, gestational age of ≥ 28 weeks or crown-to-heel length of ≥ 35 cm. It is expressed as the number of stillbirths per 1000 births. A stillbirth is defined as “death prior to the complete expulsion or extraction from its mother of a product of conception; the death is indicated by the fact that after such separation the fetus does not breathe or show any other evidence of life, such as beating of the heart, pulsation of the umbilical cord, or definite movement of voluntary muscles without specification of the duration of pregnancy”. 3. Perinatal mortality rate: The sum of the number of stillbirths and early neonatal deaths divided by the number of pregnancies of seven or more months’ duration, expressed per 1000. 48 validation of eenc monitoring and evaluation data from eight priority countries eenc scale-up readiness benchmarks Ten benchmarks are used to track scale-up readiness for EENC. All eight priority countries pro- vided data for at least nine benchmarks, with data available for 95% of benchmarks overall. Eighty-nine per cent of available data were validated. Data were least often validated for the benchmarks “EENC stakeholder group formed” and “mechanisms established to ensure that professional associations are supporting implementation of EENC”. taBle a 3.1 Summary of the availability of data on EENC scale-up readiness benchmarks and validation status by country, June 2017 indicator ca m Bo d ia ch in a la o p eo pl e' s de m . r ep uB li c m o n g o li a pa pu a n eW g u in ea ph il ip pi n es so lo m o n is la n d s vi et n a m n/n (%) Scale-up readiness benchmarks (N = 80 1) data available 9 9 10 10 10 10 9 9 76/80 (95%) data partially available 0 0 0 0 0 0 0 0 0/80 (0%) data not available 1 1 0 0 0 0 1 1 4/80 (5%) validated 2 7 5 9 6 8 8 9 7 59/66 (89%) not validated 2 1 0 1 2 1 1 0 1 7/66 (11%) 1. Number of benchmarks per country is 10; across eight countries data were collected for 10 × 8 = 80 indicators. 2. Validation of data applies only to those benchmarks for which data were available, and for benchmarks that had been achieved or partially achieved. annex 3 49 eenc facility standards Twenty-three indicators are reported for EENC facility standards. Data were available for 65% of indicators across all countries (a doubling of availability from 2015), partially available for 31% and not available for 4%. A total of 95% of all indicators were validated. Data validation was not possible for a few indicators where supporting data were not provided or were not adequate for validation. taBle a 3.2 Summary of the availability of data on EENC facility standards and validation status by country, June 2017 indicator ca m Bo d ia ch in a la o p eo pl e' s de m . r ep uB li c m o n g o li a pa pu a n eW g u in ea ph il ip pi n es so lo m o n is la n d s vi et n a m n/n (%) Implementation indicators – Roll-out of EENC (N = 184 1) data available 23 23 22 3 2 3 22 22 120/184 (65%) data partially available 0 0 0 19 18 19 0 0 56/184 (31%) data not available 0 0 1 1 3 1 1 1 8/184 (4%) validated 2 23 22 22 22 19 20 18 22 168/176 (95%) not validated 2 0 1 0 0 1 2 4 0 8/176 (5%) 1. Number of indicators per country is 23; across eight countries data were collected for 23 × 8 = 184 indicators. 2. Validation was conducted for indicators with data available or partially available. second BIENNIAL PROGRESS REPORT (2016–2017) 50 eenc hospital impact indicators Nine indicators are reported on hospital impact. Of reporting hospitals, complete data were available for 71% of indicators, and data partially available for 12% of indicators. Ninety-eight percent of indicators with complete or partial data were validated. taBle a 3.3 Summary of the availability of data on EENC hospital impact indicators and validation status by country, June 2017 indicator ca m Bo d ia ch in a la o p eo pl e' s de m . r ep uB li c m o n g o li a pa pu a n eW g u in ea ph il ip pi n es so lo m o n is la n d s vi et n a m n/n (%) Hospital impact indicators – Roll-out of EENC (N = 72 1) proportion of hospitals that have introduced eenc reporting data 2 3/ 104 0/ 6 17/ 53 25/ 26 3/ 19 24/ 428 6/ 7 2/ 687 80/ 1330 (6%) data available 9 0 6 9 9 9 9 0 51/72 (71%) data partially available 0 0 0 0 0 0 0 9 9/72 (12%) data not available 0 9 3 0 0 0 0 0 12/72 (17%) validated 3 9 0 6 9 8 9 9 9 59/60 (98%) not validated 3 0 0 0 0 1 0 0 0 1/60 (2%) 1. Number of indicators per country is 9; across eight countries data were collected for 9 × 8 = 72 indicators. 2. Number of national and regional, and first-level referral hospitals that have introduced EENC at the time of data collection. 3. Validation was conducted for indicators with data available or partially available. 51 eenc population coverage indicators Thirteen indicators are reported to track population-based coverage. Coverage indicators were reported by eight countries and were available for 67% of all indicators, with 91% of indicators validated. taBle a 3.4 Summary of the availability of data on population coverage indicators and validation status by country, June 2017 indicator ca m Bo d ia ch in a la o p eo pl e' s de m . r ep uB li c m o n g o li a pa pu a n eW g u in ea ph il ip pi n es so lo m o n is la n d s vi et n a m n/n (%) Coverage indicators for EENC (N = 104 1) data available 10 7 9 9 3 11 10 11 70/104 (67%) data not available 3 6 4 4 10 2 3 2 34/104 (33%) validated 2 10 7 9 9 0 11 10 8 64/70 (91%) not validated 2 0 0 0 0 3 0 0 3 6/70 (9%) 1. Number of indicators per country is 13; across eight countries, data were collected for 13 × 8 = 104 indicators. 2. Validation was conducted for indicators with data available. second BIENNIAL PROGRESS REPORT (2016–2017) 52 eenc impact indicators Five indicators tracking newborn health impact were reported by all eight countries. Eighty-five per cent of impact indicators were reported by countries; no data were available for 13% of indicators; and 94% of all indicators were validated. taBle a 3.5 Summary of the availability of data on impact indicators and validation status by country, June 2017 indicators ca m Bo d ia ch in a la o p eo pl e' s de m . r ep uB li c m o n g o li a pa pu a n eW g u in ea ph il ip pi n es so lo m o n is la n d s vi et n a m n/n (%) Impact indicators for EENC (N = 40 1) data available 5 5 4 3 3 5 5 4 34/40 (85%) data partially available 0 0 0 1 0 0 0 0 1/40 (2%) data not available 0 0 1 1 2 0 0 1 5/40 (13%) validated 2 5 3 4 4 3 5 5 4 33/35 (94%) not validated 2 0 2 0 0 0 0 0 0 2/35 (6%) 1. Number of indicators per country is 5; across 8 countries, data were collected for 5 × 8 = 40 indicators. 2. Validation was conducted for indicators with data available or partially available. 53 89 99.9 99.6 73 86 98 83 99.7 99.6 85 97 61 52 N o da ta fo r P ap ua N ew G ui ne a 38 6 34 4 25 9 6 28 53 42 Po pu la tio n co ve ra ge (i n % ) Skilled birth attendance Facility delivery rate Caesarean section rate 100 80 60 40 20 0 annex 4 figure a 4.1 Population coverage for skilled birth attendance, facility delivery and caesarean section, eight countries, 2006–2016 figure a 4.2 Population coverage for prelacteal feeding, early breastfeeding and exclusive breastfeeding from 0 to 1 month, eight countries, 2006–2016 Source of data: Country Demographic and Health Surveys and Multiple Indicator Cluster Surveys, 2006–2015. National Health Statistics Annual Report of China, 2016. Mongolia Health Indicators, 2015. Viet Nam National Reproductive Health Annual Report, 2016. 4 N o da ta fo r C hi na N o da ta fo r P ap ua N ew G ui ne a N o da ta fo r P ap ua N ew G ui ne a N o da ta fo r C hi na N o da ta fo r C hi na N o da ta fo r t he L ao P eo pl e' s De m oc ra tic R ep ub lic N o da ta fo r M on go lia 36 72 50 79 73 80 90 87 27 24 26 63 95 80 34 39 Po pu la tio n co ve ra ge (i n % ) Newborns receiving a prelacteal feed Newborns breastfed within 1 hour of birth Newborns exclusively breastfed from 0 to 1 month 100 80 60 40 20 0 Source of data: Country Demographic and Health Surveys and Multiple Indicator Cluster Surveys, 2006–2015. National Health Statistics Annual Report of China, 2016. Mongolia Health Indicators, 2015. Viet Nam National Reproductive Health Annual Report, 2016 (for indicator on newborns breastfed within 1 hour of birth). solomon islands solomon islands philippines philippines papua neW guinea papua neW guinea mongolia mongolia lao people's democratic repuBlic lao people's democratic repuBlic china china camBodia camBodia viet nam viet nam eenc population coverage indicators 54 second BIENNIAL PROGRESS REPORT (2016–2017) figure a 4.3 Population coverage for maternal and newborn postnatal care, eight countries, 2006–2016 69 95 N o da ta fo r P ap ua N ew G ui ne a N o da ta fo r P ap ua N ew G ui ne a 72 90 16 89 53 90 40 94 98 77 95 41 Po pu la tio n co ve ra ge (i n % ) Mothers receiving postnatal care within 2 days of birth Newborns receiving postnatal care within 2 days of birth 100 80 60 40 20 0 Source of data: Country Demographic and Health Surveys and Multiple Indicator Cluster Surveys, 2006–2015. National Health Statistics Annual Report of China, 2016. Mongolia Health Indicators, 2015. solomon islands philippines papua neW guinea mongolia lao people's democratic repuBlic china camBodia viet nam eenc country profiles camBodia 56 china 58 lao people's democratic repuBlic 60 mongolia 62 papua neW guinea 64 philippines 66 solomon islands 68 viet nam 70 For all the above countries, the country profiles break into: – Neonatal mortality rate – Causes of neonatal death – Programme readiness for EENC scale-up – Stock-outs of key medicines and commodities for EENC in the past 12 months – Coverage of key interventions – EENC implementation – Antenatal care and delivery practices – Newborn care practices: » Preterm » Term babies – Environmental hygiene – Key Points 55 annex 5 56 early essential neWBorn care CAMBODIA (1) 0 20 40 60 80 100 Percentage of term babies Data from interviews with postpartum mothers: – 34 at national hospitals (n = 3), and – 118 at subnational health facilities (n = 17) 9 10 Prolonged (≥ 90 min) skin-to-skin contact 65 77Immediate skin-to-skin contact 50 49 Sustained skin-to-skin contact until first breastfeed 32 64 Received early and exclusive breastfeeding 81 85Bathed in > 24 hours 21 64Skin-to-skin contact applied in C-section deliveries national hospital subnational hospital TERM BABIES, 20174 C BODIA NEONATAL MORTALITY RATE 1 1990 2014 2020 37 18 14 Neonatal deaths (per 1000 live births) Target in national EENC 5-year action plan CAUSES OF NEONATAL DEATH, 20162 Preterm 31% Sepsis/ Pneumonia 22% Asphyxia 23% Congenital anomalies 16% Other 8% Detailed 12-month EENC implementation plan developed and funded EENC technical working group formed 1. Cambodia Demographic and Health Surveys, 2000 and 2014. 2. WHO Global Health Observatory Data, 2018. 3. Ministry of Health, Cambodia, 2017. 4. Assessments of 20 selected health facilities that have introduced immediate newborn care (INC), 2017. 5. Adequate handwashing facilities defined as having at least one sink in the room, and all sinks in the room having running water, soap, and single-use towels/re-usable sterile towels/hand dryers available. 6. Adequate hand hygiene comprises washing hands twice before gloving and using sterile gloves to cut the umbilical cord. 7. Does not include staff coached at national hospitals, n = 254. Data on denominator not available from national hospitals. 8. Data from assessments of 15 randomly selected hospitals that have introduced INC, 2017. 9. Quality improvement approach consists of: (1) regular and documented meetings of the EENC team, (2) at least two EENC assessments per year, and (3) developing and updating an EENC hospital action plan at least quarterly. Data from 15 national, regional, and first-level referral hospitals. 10. Data from observations of 5 deliveries at 2 national hospitals and 7 deliveries at 6 subnational health facilities. PARTIAL EENC included in pre-service curricula (medical, midwifery and nursing) EENC 5-year action plan developed, costed and adopted Clinical intra-partum and newborn care protocol adapted, reviewed and endorsed YES NO STOCK-OUTS OF KEY MEDICINES AND COMMODITIES FOR EENC IN THE PAST 12 MONTHS, 20174 Antibiotics for sepsis Vitamin K Corticosteroids Magnesium sulfate Oxytocin Functional bag and mask within 2 m of delivery beds Hepatitis B vaccine 0 1 2–4 > 4 Number of stock-outs across 20 health facilities (3 national hospitals and 17 subnational health facilities) 0 20 40 60 80 100 0 20 40 60 80 100 Percentage of postpartum mothers Percentage of preterm babies Data from interviews and chart reviews of postpartum mothers: – 38 at national hospitals (n = 3), and – 126 at subnational health facilities (n = 17) Data from interviews and chart reviews of postpartum mothers: – 4 at national hospitals (n = 3), and – 8 at subnational health facilities (n = 7) Data from observations in 20 health facilities (3 national hospitals and 17 subnational health facilities) 76 76 97 Encouraged to eat and drink during labour 15 4Syphilis testing recorded 33 33 Pregnant women* at risk of preterm labour receiving corticosteroids 50 75Immediate skin-to-skin contact 81With companion during childbirth Prolonged (≥ 90 min) skin-to-skin contact 26 3Episiotomy 86 80Oxytocin injected within 1 min of birth10 82 88Partographs completed correctly 38 Sustained skin-to-skin contact until first breastfeed national hospital national hospital subnational hospital subnational hospital 95 Not in supine position during active labour Pregnant women < 32 weeks of gestational age receiving MgSO4 0 no sample 0 0 Received Kangaroo Mother Care 0 63 Received early and exclusive breastfeeding 0 ANTENATAL CARE AND DELIVERY PRACTICES, 20174 ENVIRONMENTAL HYGIENE, 20174 KEY POINTS • 51% of all under-5 deaths in Cambodia occur in the newborn period. • Immediate newborn care (INC) is implemented in Cambodia. INC coaching has been done in 5/6 national hospitals – all provincial hospitals – and over 90% operational district hospitals and first- level health facilities. • A high proportion of maternity and paediatric staff have been coached in EENC, including 80% in provincial hospitals and close to 70% in operational district hospitals. • Around 80% of pregnant women have a correctly completed parto- graph in their patient chart, are encouraged to assume a position of choice and have a companion during childbirth. • Preterm newborns are less likely to receive EENC, which puts them at higher risk of poor health outcomes. • Stock-outs of essential medicines and commodities are experienced mostly in subnational health facilities. • No health facilities assessed have adequate sink handwashing facilities, while 1 in 3 have alcohol gel/hand rub available in all maternity and neonatal care rooms. Adequate hand hygiene6 practised in 73% of deliveries 35% of health facilities have alcohol gel/hand rub available in all delivery, recovery, postnatal and neonatal care rooms 0% of health facilities have adequate sink handwashing facilities5 in all delivery, recovery, postnatal and neonatal care rooms 75% of health facilities have clean and dry newborn resuscitation areas PRETERM BABIES, 20174 NEWBORN CARE PRACTICES * Women of 24–34 weeks of gestational age no data 82 Percentage COVERAGE OF KEY INTERVENTIONS, 20141 0 20 40 60 80 100 89Skilled attendance at birth 83Facility delivery rate 6Births delivered by caesarean section 63Breastfeeding initiated within ≤ 1 hour of birth 90Women who received PNC* in ≤ 2 days of birth 77Newborns who received PNC* in ≤ 2 days of birth introduced in 90% of health facilities (1139/1272) 71% of staff coached7 (3803/5347) 27% have EENC teams8 13% have established a quality improvement approach8,9 * postnatal care EENC 71% 27% 13% Of the facilities that have introduced EENC: EENC IMPLEMENTATION, 20173 Skin-to-skin contact no data Exclusive breastfeeding from 0 to 1 month 80 PROGRAMME READINESS FOR EENC SCALE-UP 20173 Early EssEntial nEwborn CarE (EEnC) 2017 0 10 20 30 40 50 60 W PR /2 01 7/ DN H/ 00 9 – © W or ld H ea lth O rg an iza tio n 20 17 – S om e rig ht s re se rv ed . T hi s w or k is av ai la bl e un de r t he C C BY -N C- SA 3 .0 IG O li ce ns e. second BIENNIAL PROGRESS REPORT (2016–2017) 57 CAMBODIA (2) early essential neWBorn care 0 20 40 60 80 100 Percentage of term babies Data from interviews with postpartum mothers: – 34 at national hospitals (n = 3), and – 118 at subnational health facilities (n = 17) 9 10 Prolonged (≥ 90 min) skin-to-skin contact 65 77Immediate skin-to-skin contact 50 49 Sustained skin-to-skin contact until first breastfeed 32 64 Received early and exclusive breastfeeding 81 85Bathed in > 24 hours 21 64Skin-to-skin contact applied in C-section deliveries national hospital subnational hospital TERM BABIES, 20174 CAMBODIA NEONATAL MORTALITY RATE 1 1990 2014 2020 37 18 14 Neonatal deaths (per 1000 live births) Target in national EENC 5-year action plan CAUSES OF NEONATAL DEATH, 20162 Preterm 31% Sepsis/ Pneumonia 22% Asphyxia 23% Congenital anomalies 16% Other 8% Detailed 12-month EENC implementation plan developed and funded EENC technical working group formed 1. Cambodia Demographic and Health Surveys, 2000 and 2014. 2. WHO Global Health Observatory Data, 2018. 3. Ministry of Health, Cambodia, 2017. 4. Assessments of 20 selected health facilities that have introduced immediate newborn care (INC), 2017. 5. Adequate handwashing facilities defined as having at least one sink in the room, and all sinks in the room having running water, soap, and single-use towels/re-usable sterile towels/hand dryers available. 6. Adequate hand hygiene comprises washing hands twice before gloving and using sterile gloves to cut the umbilical cord. 7. Does not include staff coached at national hospitals, n = 254. Data on denominator not available from national hospitals. 8. Data from assessments of 15 randomly selected hospitals that have introduced INC, 2017. 9. Quality improvement approach consists of: (1) regular and documented meetings of the EENC team, (2) at least two EENC assessments per year, and (3) developing and updating an EENC hospital action plan at least quarterly. Data from 15 national, regional, and first-level referral hospitals. 10. Data from observations of 5 deliveries at 2 national hospitals and 7 deliveries at 6 subnational health facilities. PARTIAL EENC included in pre-service curricula (medical, midwifery and nursing) EENC 5-year action plan developed, costed and adopted Clinical intra-partum and newborn care protocol adapted, reviewed and endorsed YES NO STOCK-OUTS OF KEY MEDICINES AND COMMODITIES FOR EENC IN THE PAST 12 MONTHS, 20174 Antibiotics for sepsis Vitamin K Corticosteroids Magnesium sulfate Oxytocin Functional bag and mask within 2 m of delivery beds Hepatitis B vaccine 0 1 2–4 > 4 Number of stock-outs across 20 health facilities (3 national hospitals and 17 subnational health facilities) 0 20 40 60 80 100 0 20 40 60 80 100 Percentage of postpartum mothers Percentage of preterm babies Data from interviews and chart reviews of postpartum mothers: – 38 at national hospitals (n = 3), and – 126 at subnational health facilities (n = 17) Data from interviews and chart reviews of postpartum mothers: – 4 at national hospitals (n = 3), and – 8 at subnational health facilities (n = 7) Data from observations in 20 health facilities (3 national hospitals and 17 subnational health facilities) 76 76 97 Encouraged to eat and drink during labour 15 4Syphilis testing recorded 33 33 Pregnant women* at risk of preterm labour receiving corticosteroids 50 75Immediate skin-to-skin contact 81With companion during childbirth Prolonged (≥ 90 min) skin-to-skin contact 26 3Episiotomy 86 80Oxytocin injected within 1 min of birth10 82 88Partographs completed correctly 38 Sustained skin-to-skin contact until first breastfeed national hospital national hospital subnational hospital subnational hospital 95 Not in supine position during active labour Pregnant women < 32 weeks of gestational age receiving MgSO4 0 no sample 0 0 Received Kangaroo Mother Care 0 63 Received early and exclusive breastfeeding 0 ANTENATAL CARE AND DELIVERY PRACTICES, 20174 ENVIRONMENTAL HYGIENE, 20174 KEY POINTS • 51% of all under-5 deaths in Cambodia occur in the newborn period. • Immediate newborn care (INC) is implemented in Cambodia. INC coaching has been done in 5/6 national hospitals – all provincial hospitals – and over 90% operational district hospitals and first- level health facilities. • A high proportion of maternity and paediatric staff have been coached in EENC, including 80% in provincial hospitals and close to 70% in operational district hospitals. • Around 80% of pregnant women have a correctly completed parto- graph in their patient chart, are encouraged to assume a position of choice and have a companion during childbirth. • Preterm newborns are less likely to receive EENC, which puts them at higher risk of poor health outcomes. • Stock-outs of essential medicines and commodities are experienced mostly in subnational health facilities. • No health facilities assessed have adequate sink handwashing facilities, while 1 in 3 have alcohol gel/hand rub available in all maternity and neonatal care rooms. Adequate hand hygiene6 practised in 73% of deliveries 35% of health facilities have alcohol gel/hand rub available in all delivery, recovery, postnatal and neonatal care rooms 0% of health facilities have adequate sink handwashing facilities5 in all delivery, recovery, postnatal and neonatal care rooms 75% of health facilities have clean and dry newborn resuscitation areas PRETERM BABIES, 20174 NEWBORN CARE PRACTICES * Women of 24–34 weeks of gestational age no data 82 Percentage COVERAGE OF KEY INTERVENTIONS, 20141 0 20 40 60 80 100 89Skilled attendance at birth 83Facility delivery rate 6Births delivered by caesarean section 63Breastfeeding initiated within ≤ 1 hour of birth 90Women who received PNC* in ≤ 2 days of birth 77Newborns who received PNC* in ≤ 2 days of birth introduced in 90% of health facilities (1139/1272) 71% of staff coached7 (3803/5347) 27% have EENC teams8 13% have established a quality improvement approach8,9 * postnatal care EENC 71% 27% 13% Of the facilities that have introduced EENC: EENC IMPLEMENTATION, 20173 Skin-to-skin contact no data Exclusive breastfeeding from 0 to 1 month 80 PROGRAMME READINESS FOR EENC SCALE-UP 20173 Early EssEntial nEwborn CarE (EEnC) 2017 0 10 20 30 40 50 60 W PR /2 01 7/ DN H/ 00 9 – © W or ld H ea lth O rg an iza tio n 20 17 – S om e rig ht s re se rv ed . T hi s w or k is av ai la bl e un de r t he C C BY -N C- SA 3 .0 IG O li ce ns e. early essential neWBorn care CHINA (1) Early EssEntial nEwborn CarE (EEnC) 2017 HINA NEONATAL MORTALITY RATE 1 1990 2016 2020 30 5 10 Neonatal deaths (per 1000 live births) Target in regional action plan CAUSES OF NEONATAL DEATH, 20162 Preterm 31% Sepsis/ Pneumonia 8% Asphyxia 28% Congenital anomalies 18% Other 14% Diarrhoea 1% Detailed 12-month EENC implementation plan developed and funded EENC technical working group formed 1. Level and Trends in Child Mortality: Report 2017. UNICEF, 2017. China Maternal and Child Mortality Surveillance Report, 2016. 2. WHO Global Health Observatory, 2018. 3. Ministry of Health, 2017. 4. Assessments of the 6 hospitals that have introduced EENC, 2016. 5. Adequate handwashing facilities defined as having at least one sink in the room, and all sinks in the room having running water, soap, and single-use towels/re-usable sterile towels/hand dryers available. 6. Adequate hand hygiene comprises washing hands twice before gloving and using sterile gloves to cut the umbilical cord. 7. China National Health Statistics Annual Report, 2016. China Maternal and Child Surveillance Report, 2016. 8. Quality improvement approach consists of: (1) regular and documented meetings of the EENC team, (2) at least two EENC assessments per year, and (3) developing and updating an EENC hospital action plan at least quarterly. 9. Data from observations of 8 deliveries at 3 national hospitals and 8 deliveries at 3 subnational hospitals. PARTIAL EENC included in pre-service curricula (medical, midwifery and nursing) EENC 5-year action plan developed, costed and adopted Clinical intra-partum and newborn care protocol adapted, reviewed and endorsed YES NO STOCK-OUTS OF KEY MEDICINES AND COMMODITIES FOR EENC IN THE PAST 12 MONTHS, 20164 Antibiotics for sepsis Vitamin K Corticosteroids Magnesium sulfate Oxytocin Functional bag and mask within 2 m of delivery beds Hepatitis B vaccine 0 1 2–4 > 4 Number of stock-outs across 6 hospitals (3 national hospitals and 3 subnational hospitals) 0 20 40 60 80 100 Percentage of preterm babies Data from interviews and chart reviews of postpartum mothers: – 13 at national hospitals (n = 3), and – 3 at subnational hospitals (n = 3) Data from observations in 6 hospitals (3 national hospitals and 3 subnational hospitals) 100 100 Pregnant women* at risk of preterm labour receiving corticosteroids 38 33Immediate skin-to-skin contact 23Prolonged (≥ 90 min) skin-to-skin contact 33 23Sustained skin-to-skin contact until first breastfeed national hospital subnational hospital Pregnant women < 32 weeks of gestational age receiving MgSO4 Received Kangaroo Mother Care Received early and exclusive breastfeeding 0 ENVIRONMENTAL HYGIENE, 20164 KEY POINTS • 51% of all under-5 deaths in China now occur in the newborn period. • A national EENC technical working group has been formed, while work on funding an annual implementation plan and endorsing a clinical protocol is on-going. • Six health facilities introduced EENC in 2016, and 84% of staff pro- viding childbirth and newborn care have been coached. • The majority of women have syphilis testing recorded in their patient charts, are encouraged to eat and drink during labour, and have correctly completed partographs. However, few women assume a non-supine position during the active stage of labour or have a companion during childbirth. • Preterm newborns are less likely to receive EENC, which puts them at higher risk of poor health outcomes. • All key medicines and commodities for EENC are available in hospi- tals. One in three hospitals have adequate hand sink handwashing facilities in all maternal and neonatal care rooms. Adequate hand hygiene6 practised in 94% of deliveries 17% of hospitals have alcohol gel/hand rub available in all delivery, recovery, postnatal and neonatal care rooms 33% of hospitals have adequate sink handwashing facilities5 in all delivery, recovery, postnatal and neonatal care rooms 100% of hospitals have clean and dry newborn resuscitation areas PRETERM BABIES, 20164 * Women of 24–34 weeks of gestational age 8 8 0 0 0 20 40 60 80 100 Percentage of postpartum mothers Data from interviews and chart reviews of postpartum mothers: – 26 at national hospitals (n = 3) and – 28 at subnational hospitals (n = 3) 92 76 71 Encouraged to eat and drink during labour 84 100Syphilis testing recorded 21With companion during childbirth 25 27Episiotomy 63 50Oxytocin injected within 1 min of birth9 96 100Partographs completed correctly national hospital subnational hospital 50 Not in supine position during active labour ANTENATAL CARE AND DELIVERY PRACTICES, 20164 50 7 Percentage COVERAGE OF KEY INTERVENTIONS, 20157 0 20 40 60 80 100 99.9Skilled attendance at birth 99.7Facility delivery rate 34.0Births delivered by caesarean section Breastfeeding initiated within ≤ 1 hour of birth 95.0Women who received PNC* in ≤ 2 days of birth 94.0Newborns who received PNC* in ≤ 2 days of birth introduced in 0.02% of health facilities (6/25 860) 84% of staff coached (981/1167) 100% have EENC teams 50% have established a quality improvement approach8 * postnatal care EENC 84% 100% 50% Of the facilities that have introduced EENC: EENC IMPLEMENTATION, 20173 Skin-to-skin contact no data no data Exclusive breastfeeding from 0 to 1 month no data 0 20 40 60 80 100 Percentage of term babies Data from interviews with postpartum mothers: – 26 at national hospitals (n = 3), and – 28 at subnational hospitals (n = 3) 73 79 Prolonged (≥ 90 min) skin-to-skin contact 88 86Immediate skin-to-skin contact 85 61 Sustained skin-to-skin contact until first breastfeed 46 57 Received early and exclusive breastfeeding 100 100Bathed in > 24 hours 0Skin-to-skin contact applied in C-section deliveries national hospital TERM BABIES, 20164 NEWBORN CARE PRACTICES no data 100 100 PROGRAMME READINESS FOR EENC SCALE-UP 20173 subnational hospital 0 10 20 30 40 50 60 W PR /2 01 7/ DN H/ 01 0 – © W or ld H ea lth O rg an iza tio n 20 17 – S om e rig ht s re se rv ed . T hi s w or k is av ai la bl e un de r t he C C BY -N C- SA 3 .0 IG O li ce ns e. 58 second BIENNIAL PROGRESS REPORT (2016–2017) CHINA (2) early essential neWBorn care Early EssEntial nEwborn CarE (EEnC) 2017 CHINA NEONATAL MORTALITY RATE 1 1990 2016 2020 30 5 10 Neonatal deaths (per 1000 live births) Target in regional action plan CAUSES OF NEONATAL DEATH, 20162 Preterm 31% Sepsis/ Pneumonia 8% Asphyxia 28% Congenital anomalies 18% Other 14% Diarrhoea 1% Detailed 12-month EENC implementation plan developed and funded EENC technical working group formed 1. Level and Trends in Child Mortality: Report 2017. UNICEF, 2017. China Maternal and Child Mortality Surveillance Report, 2016. 2. WHO Global Health Observatory, 2018. 3. Ministry of Health, 2017. 4. Assessments of the 6 hospitals that have introduced EENC, 2016. 5. Adequate handwashing facilities defined as having at least one sink in the room, and all sinks in the room having running water, soap, and single-use towels/re-usable sterile towels/hand dryers available. 6. Adequate hand hygiene comprises washing hands twice before gloving and using sterile gloves to cut the umbilical cord. 7. China National Health Statistics Annual Report, 2016. China Maternal and Child Surveillance Report, 2016. 8. Quality improvement approach consists of: (1) regular and documented meetings of the EENC team, (2) at least two EENC assessments per year, and (3) developing and updating an EENC hospital action plan at least quarterly. 9. Data from observations of 8 deliveries at 3 national hospitals and 8 deliveries at 3 subnational hospitals. PARTIAL EENC included in pre-service curricula (medical, midwifery and nursing) EENC 5-year action plan developed, costed and adopted Clinical intra-partum and newborn care protocol adapted, reviewed and endorsed YES NO STOCK-OUTS OF KEY MEDICINES AND COMMODITIES FOR EENC IN THE PAST 12 MONTHS, 20164 Antibiotics for sepsis Vitamin K Corticosteroids Magnesium sulfate Oxytocin Functional bag and mask within 2 m of delivery beds Hepatitis B vaccine 0 1 2–4 > 4 Number of stock-outs across 6 hospitals (3 national hospitals and 3 subnational hospitals) 0 20 40 60 80 100 Percentage of preterm babies Data from interviews and chart reviews of postpartum mothers: – 13 at national hospitals (n = 3), and – 3 at subnational hospitals (n = 3) Data from observations in 6 hospitals (3 national hospitals and 3 subnational hospitals) 100 100 Pregnant women* at risk of preterm labour receiving corticosteroids 38 33Immediate skin-to-skin contact 23Prolonged (≥ 90 min) skin-to-skin contact 33 23Sustained skin-to-skin contact until first breastfeed national hospital subnational hospital Pregnant women < 32 weeks of gestational age receiving MgSO4 Received Kangaroo Mother Care Received early and exclusive breastfeeding 0 ENVIRONMENTAL HYGIENE, 20164 KEY POINTS • 51% of all under-5 deaths in China now occur in the newborn period. • A national EENC technical working group has been formed, while work on funding an annual implementation plan and endorsing a clinical protocol is on-going. • Six health facilities introduced EENC in 2016, and 84% of staff pro- viding childbirth and newborn care have been coached. • The majority of women have syphilis testing recorded in their patient charts, are encouraged to eat and drink during labour, and have correctly completed partographs. However, few women assume a non-supine position during the active stage of labour or have a companion during childbirth. • Preterm newborns are less likely to receive EENC, which puts them at higher risk of poor health outcomes. • All key medicines and commodities for EENC are available in hospi- tals. One in three hospitals have adequate hand sink handwashing facilities in all maternal and neonatal care rooms. Adequate hand hygiene6 practised in 94% of deliveries 17% of hospitals have alcohol gel/hand rub available in all delivery, recovery, postnatal and neonatal care rooms 33% of hospitals have adequate sink handwashing facilities5 in all delivery, recovery, postnatal and neonatal care rooms 100% of hospitals have clean and dry newborn resuscitation areas PRETERM BABIES, 20164 * Women of 24–34 weeks of gestational age 8 8 0 0 0 20 40 60 80 100 Percentage of postpartum mothers Data from interviews and chart reviews of postpartum mothers: – 26 at national hospitals (n = 3) and – 28 at subnational hospitals (n = 3) 92 76 71 Encouraged to eat and drink during labour 84 100Syphilis testing recorded 21With companion during childbirth 25 27Episiotomy 63 50Oxytocin injected within 1 min of birth9 96 100Partographs completed correctly national hospital subnational hospital 50 Not in supine position during active labour ANTENATAL CARE AND DELIVERY PRACTICES, 20164 50 7 Percentage COVERAGE OF KEY INTERVENTIONS, 20157 0 20 40 60 80 100 99.9Skilled attendance at birth 99.7Facility delivery rate 34.0Births delivered by caesarean section Breastfeeding initiated within ≤ 1 hour of birth 95.0Women who received PNC* in ≤ 2 days of birth 94.0Newborns who received PNC* in ≤ 2 days of birth introduced in 0.02% of health facilities (6/25 860) 84% of staff coached (981/1167) 100% have EENC teams 50% have established a quality improvement approach8 * postnatal care EENC 84% 100% 50% Of the facilities that have introduced EENC: EENC IMPLEMENTATION, 20173 Skin-to-skin contact no data no data Exclusive breastfeeding from 0 to 1 month no data 0 20 40 60 80 100 Percentage of term babies Data from interviews with postpartum mothers: – 26 at national hospitals (n = 3), and – 28 at subnational hospitals (n = 3) 73 79 Prolonged (≥ 90 min) skin-to-skin contact 88 86Immediate skin-to-skin contact 85 61 Sustained skin-to-skin contact until first breastfeed 46 57 Received early and exclusive breastfeeding 100 100Bathed in > 24 hours 0Skin-to-skin contact applied in C-section deliveries national hospital TERM BABIES, 20164 NEWBORN CARE PRACTICES no data 100 100 PROGRAMME READINESS FOR EENC SCALE-UP 20173 subnational hospital 0 10 20 30 40 50 60 W PR /2 01 7/ DN H/ 01 0 – © W or ld H ea lth O rg an iza tio n 20 17 – S om e rig ht s re se rv ed . T hi s w or k is av ai la bl e un de r t he C C BY -N C- SA 3 .0 IG O li ce ns e. 59 early essential neWBorn care LAO PEOPLE'S DEMOCRATIC REPUBLIC (1)LAO PEOPLE’S D OCRATIC REPUBLIC NEONATAL MORTALITY RATE 1 1990 2011 2016 2020 54 32 29 20 Neonatal deaths (per 1000 live births) Target in national EENC 5-year action plan CAUSES OF NEONATAL DEATH, 20152 Preterm 28% Sepsis/ Pneumonia 23% Asphyxia 29% Congenital anomalies 10% Other 9% Diarrhoea 1% PROGRAMME READINESS FOR EENC SCALE-UP 20173 Detailed 12-month EENC implementation plan developed and funded EENC technical working group formed 1. Level and Trends in Child Mortality: Report 2017. UNICEF, 2017. Lao Social Indicator Survey (LSIS) 2011–2012. 2. WHO Global Health Observatory Data, 2018. 3. Ministry of Health, Lao People’s Democratic Republic, 2017. 4. Assessment of 18 randomly selected hospitals that have introduced EENC, 2016. 5. Adequate handwashing facilities defined as having at least one sink in the room, and all sinks in the room having running water, soap, and single-use towels/re-usable sterile towels/hand dryers available. 6. Adequate hand hygiene comprises washing hands twice before gloving and using sterile gloves to cut the umbilical cord. 7. LSIS 2011–2012. 8. Quality improvement approach consists of: (1) regular and documented meetings of the EENC team, (2) at least two EENC assessments per year, and (3) developing and updating an EENC hospital action plan at least quarterly. 9. Data from observations of 13 deliveries at 3 national hospitals and 8 deliveries at 6 subnational hospitals. PARTIAL EENC included in pre-service curricula (medical, midwifery and nursing) EENC 5-year action plan developed, costed and adopted Clinical intra-partum and newborn care protocol adapted, reviewed and endorsed YES NO STOCK-OUTS OF KEY MEDICINES AND COMMODITIES FOR EENC IN THE PAST 12 MONTHS, 20164 Antibiotics for sepsis Vitamin K Corticosteroids Magnesium sulfate Oxytocin Functional bag and mask within 2 m of delivery beds Hepatitis B vaccine 0 1 2–4 > 4 Number of stock-outs across 18 hospitals (4 national hospitals and 14 subnational hospitals) 0 20 40 60 80 100 Percentage of preterm babies Data from interviews and chart reviews of postpartum mothers: – 8 at national hospitals (n = 2), and – 9 at subnational hospitals (n = 7) Data from observations in 18 hospitals (4 national hospitals and 14 subnational hospitals) 88 33 Pregnant women* at risk of preterm labour receiving corticosteroids 50 56Immediate skin-to-skin contact 22 13Prolonged (≥ 90 min) skin-to-skin contact 33 13Sustained skin-to-skin contact until first breastfeed national hospital subnational hospital Pregnant women < 32 weeks of gestational age receiving MgSO4 0 Received Kangaroo Mother Care 0 22 Received early and exclusive breastfeeding 0 ENVIRONMENTAL HYGIENE, 20164 KEY POINTS • 50% of all under-5 deaths in the Lao PDR occur in the newborn period. • EENC coaching has been done in 4/7 (57%) of national hospitals, 17/17 (100%) of provincial hospitals, and 32/137 (23%) of district, military and police hospitals. • A high proportion of maternity and paediatric staff have been coached in EENC, including 69% of staff in national hospitals and 76% of staff in provincial hospitals. • Syphilis testing is recorded for a low proportion of pregnant women. • Seventy per cent of partographs are completed correctly. • Preterm newborns are less likely to receive EENC, which puts them at higher risk of poor health outcomes. • The majority of essential medicines and commodities are available in national and provincial hospitals. • A low proportion of hospitals has adequate sink handwashing facilities and alcohol gel/hand rub available in all maternity and neonatal care rooms. Adequate hand hygiene6 practised in 70% of deliveries 17% of hospitals have alcohol gel/hand rub available in all delivery, recovery, postnatal and neonatal care rooms 6% of hospitals have adequate sink handwashing facilities5 in all delivery, recovery, postnatal and neonatal care rooms 67% of hospitals have clean and dry newborn resuscitation areas PRETERM BABIES, 20164 * Women of 24–34 weeks of gestational age 0 20 40 60 80 100 Percentage of term babies Data from interviews with postpartum mothers: – 42 at national hospitals (n = 4), and – 147 at subnational hospitals (n = 14) Prolonged (≥ 90 min) skin-to-skin contact Immediate skin-to-skin contact Sustained skin-to-skin contact until first breastfeed Received early and exclusive breastfeeding Bathed in > 24 hours 0 Skin-to-skin contact applied in C-section deliveries national hospital subnational hospital TERM BABIES, 20164 NEWBORN CARE PRACTICES 52 41 71 66 57 43 48 48 62 89 0 20 40 60 80 100 Percentage of postpartum mothers Data from interviews and chart reviews of postpartum mothers: – 42 at national hospitals (n = 4) and – 146 at subnational hospitals (n = 14) Encouraged to eat and drink during labour Syphilis testing recorded With companion during childbirth Episiotomy Oxytocin injected within 1 min of birth9 Partographs completed correctly national hospital subnational hospital Not in supine position during active labour ANTENATAL CARE AND DELIVERY PRACTICES, 20164 Percentage COVERAGE OF KEY INTERVENTIONS, 20127 0 20 40 60 80 100 42Skilled attendance at birth 38Facility delivery rate 4Births delivered by caesarean section 39Breastfeeding initiated within ≤ 1 hour of birth 40Women who received PNC* in ≤ 2 days of birth 41Newborns who received PNC* in ≤ 2 days of birth introduced in 18% of health facilities (53/299) 74% of staff coached (568/769) 94% have EENC teams 6% have established a quality improvement approach8 * postnatal care EENC 74% 94% 6% Of the facilities that have introduced EENC4: EENC IMPLEMENTATION, 20173 Skin-to-skin contact no data Exclusive breastfeeding from 0 to 1 month 64 50 28 12 1 5 30 36 100 100 59 76 5 0 no data Early EssEntial nEwborn CarE (EEnC) 2017 0 10 20 30 40 50 60 W PR /2 01 7/ DN H/ 00 7 – © W or ld H ea lth O rg an iza tio n 20 17 – S om e rig ht s re se rv ed . T hi s w or k is av ai la bl e un de r t he C C BY -N C- SA 3 .0 IG O li ce ns e. 60 second BIENNIAL PROGRESS REPORT (2016–2017) LAO PEOPLE'S DEMOCRATIC REPUBLIC (2) early essential neWBorn care LAO PEOPLE’S DEMOCRATIC REPUBLIC NEONATAL MORTALITY RATE 1 1990 2011 2016 2020 54 32 29 20 Neonatal deaths (per 1000 live births) Target in national EENC 5-year action plan CAUSES OF NEONATAL DEATH, 20152 Preterm 28% Sepsis/ Pneumonia 23% Asphyxia 29% Congenital anomalies 10% Other 9% Diarrhoea 1% PROGRAMME READINESS FOR EENC SCALE-UP 20173 Detailed 12-month EENC implementation plan developed and funded EENC technical working group formed 1. Level and Trends in Child Mortality: Report 2017. UNICEF, 2017. Lao Social Indicator Survey (LSIS) 2011–2012. 2. WHO Global Health Observatory Data, 2018. 3. Ministry of Health, Lao People’s Democratic Republic, 2017. 4. Assessment of 18 randomly selected hospitals that have introduced EENC, 2016. 5. Adequate handwashing facilities defined as having at least one sink in the room, and all sinks in the room having running water, soap, and single-use towels/re-usable sterile towels/hand dryers available. 6. Adequate hand hygiene comprises washing hands twice before gloving and using sterile gloves to cut the umbilical cord. 7. LSIS 2011–2012. 8. Quality improvement approach consists of: (1) regular and documented meetings of the EENC team, (2) at least two EENC assessments per year, and (3) developing and updating an EENC hospital action plan at least quarterly. 9. Data from observations of 13 deliveries at 3 national hospitals and 8 deliveries at 6 subnational hospitals. PARTIAL EENC included in pre-service curricula (medical, midwifery and nursing) EENC 5-year action plan developed, costed and adopted Clinical intra-partum and newborn care protocol adapted, reviewed and endorsed YES NO STOCK-OUTS OF KEY MEDICINES AND COMMODITIES FOR EENC IN THE PAST 12 MONTHS, 20164 Antibiotics for sepsis Vitamin K Corticosteroids Magnesium sulfate Oxytocin Functional bag and mask within 2 m of delivery beds Hepatitis B vaccine 0 1 2–4 > 4 Number of stock-outs across 18 hospitals (4 national hospitals and 14 subnational hospitals) 0 20 40 60 80 100 Percentage of preterm babies Data from interviews and chart reviews of postpartum mothers: – 8 at national hospitals (n = 2), and – 9 at subnational hospitals (n = 7) Data from observations in 18 hospitals (4 national hospitals and 14 subnational hospitals) 88 33 Pregnant women* at risk of preterm labour receiving corticosteroids 50 56Immediate skin-to-skin contact 22 13Prolonged (≥ 90 min) skin-to-skin contact 33 13Sustained skin-to-skin contact until first breastfeed national hospital subnational hospital Pregnant women < 32 weeks of gestational age receiving MgSO4 0 Received Kangaroo Mother Care 0 22 Received early and exclusive breastfeeding 0 ENVIRONMENTAL HYGIENE, 20164 KEY POINTS • 50% of all under-5 deaths in the Lao PDR occur in the newborn period. • EENC coaching has been done in 4/7 (57%) of national hospitals, 17/17 (100%) of provincial hospitals, and 32/137 (23%) of district, military and police hospitals. • A high proportion of maternity and paediatric staff have been coached in EENC, including 69% of staff in national hospitals and 76% of staff in provincial hospitals. • Syphilis testing is recorded for a low proportion of pregnant women. • Seventy per cent of partographs are completed correctly. • Preterm newborns are less likely to receive EENC, which puts them at higher risk of poor health outcomes. • The majority of essential medicines and commodities are available in national and provincial hospitals. • A low proportion of hospitals has adequate sink handwashing facilities and alcohol gel/hand rub available in all maternity and neonatal care rooms. Adequate hand hygiene6 practised in 70% of deliveries 17% of hospitals have alcohol gel/hand rub available in all delivery, recovery, postnatal and neonatal care rooms 6% of hospitals have adequate sink handwashing facilities5 in all delivery, recovery, postnatal and neonatal care rooms 67% of hospitals have clean and dry newborn resuscitation areas PRETERM BABIES, 20164 * Women of 24–34 weeks of gestational age 0 20 40 60 80 100 Percentage of term babies Data from interviews with postpartum mothers: – 42 at national hospitals (n = 4), and – 147 at subnational hospitals (n = 14) Prolonged (≥ 90 min) skin-to-skin contact Immediate skin-to-skin contact Sustained skin-to-skin contact until first breastfeed Received early and exclusive breastfeeding Bathed in > 24 hours 0 Skin-to-skin contact applied in C-section deliveries national hospital subnational hospital TERM BABIES, 20164 NEWBORN CARE PRACTICES 52 41 71 66 57 43 48 48 62 89 0 20 40 60 80 100 Percentage of postpartum mothers Data from interviews and chart reviews of postpartum mothers: – 42 at national hospitals (n = 4) and – 146 at subnational hospitals (n = 14) Encouraged to eat and drink during labour Syphilis testing recorded With companion during childbirth Episiotomy Oxytocin injected within 1 min of birth9 Partographs completed correctly national hospital subnational hospital Not in supine position during active labour ANTENATAL CARE AND DELIVERY PRACTICES, 20164 Percentage COVERAGE OF KEY INTERVENTIONS, 20127 0 20 40 60 80 100 42Skilled attendance at birth 38Facility delivery rate 4Births delivered by caesarean section 39Breastfeeding initiated within ≤ 1 hour of birth 40Women who received PNC* in ≤ 2 days of birth 41Newborns who received PNC* in ≤ 2 days of birth introduced in 18% of health facilities (53/299) 74% of staff coached (568/769) 94% have EENC teams 6% have established a quality improvement approach8 * postnatal care EENC 74% 94% 6% Of the facilities that have introduced EENC4: EENC IMPLEMENTATION, 20173 Skin-to-skin contact no data Exclusive breastfeeding from 0 to 1 month 64 50 28 12 1 5 30 36 100 100 59 76 5 0 no data Early EssEntial nEwborn CarE (EEnC) 2017 0 10 20 30 40 50 60 W PR /2 01 7/ DN H/ 00 7 – © W or ld H ea lth O rg an iza tio n 20 17 – S om e rig ht s re se rv ed . T hi s w or k is av ai la bl e un de r t he C C BY -N C- SA 3 .0 IG O li ce ns e. 61 early essential neWBorn care MONGOLIA (1)M NGOLIA NEONATAL MORTALITY RATE 1 1990 2015 2020 30 10 5 Neonatal deaths (per 1000 live births) Target in national EENC 5-year action plan CAUSES OF NEONATAL DEATH, 20162 Preterm 30% Sepsis/ Pneumonia 18% Asphyxia 22% Congenital anomalies 23% Other 7% Detailed 12-month EENC implementation plan developed and funded EENC technical working group formed 1. Level and Trends in Child Mortality: Report 2017. UNICEF, 2017. Mongolia Health Indicators, 2015. 2. WHO Global Health Observatory Data, 2018. 3. Ministry of Health of Mongolia, 2017. 4. Based on data from assessments of the 25 national and first-level referral hospitals that have introduced EENC. 5. Adequate handwashing facilities defined as having at least one sink in the room, and all sinks in the room having running water, soap, and single-use towels available. 6. Adequate hand hygiene comprises washing hands twice before gloving and using sterile gloves to cut the umbilical cord. 7. Mongolia Health Indicators, 2015. Social Indicator Sample Survey. National Statistics Office of Mongolia, UNFPA, UNICEF, 2013. 8. Quality improvement approach consists of: (1) regular and documented meetings of the EENC team, (2) at least two EENC assessments per year, and (3) developing and updating an EENC hospital action plan at least quarterly. 9. Data from observations of 24 deliveries in 4 national hospitals and 85 deliveries in 18 subnational hospitals. PARTIAL EENC included in pre-service curricula (medical, midwifery and nursing) EENC 5-year action plan developed, costed and adopted Clinical intra-partum and newborn care protocol adapted, reviewed and endorsed YES NO STOCK-OUTS OF KEY MEDICINES AND COMMODITIES FOR EENC IN THE PAST 12 MONTHS, 20164 Antibiotics for sepsis Vitamin K Corticosteroids Oxytocin Functional bag and mask within 2 m of delivery beds Hepatitis B vaccine 0 1 2–4 > 4 Number of stock-outs across 25 hospitals (4 national hospitals and 21 subnational hospitals) 0 20 40 60 80 100 Percentage of preterm babies Data from interviews and chart reviews of postpartum mothers: – 27 at national hospitals (n = 4), and – 45 at subnational hospitals (n = 19) Data from observations in 25 hospitals (4 national hospitals and 21 subnational hospitals) 60 88 Pregnant women* at risk of preterm labour receiving corticosteroids 48 40Immediate skin-to-skin contact 11Prolonged (≥ 90 min) skin-to-skin contact 53 44Sustained skin-to-skin contact until first breastfeed national hospital subnational hospital Pregnant women < 32 weeks of gestational age receiving MgSO4 Received Kangaroo Mother Care Received early and exclusive breastfeeding ENVIRONMENTAL HYGIENE, 20164 KEY POINTS • 50% of all under-5 deaths in Mongolia now occur in the newborn period. • EENC coaching has begun in 4/4 national and 21/21 first-level referral government hospitals and in 23/113 first-level facilities. • Seventy-four per cent of staff at national and 84% at first-level referral hospitals have been coached in EENC. • The majority of pregnant women have syphilis testing recorded, are encouraged to eat and drink, assume a non-supine position during the active stage of labour, and are injected with oxytocin within 1 minute of birth. However, less than 10% have a companion at childbirth. • Preterm newborns are less likely to receive EENC, which puts them at higher risk of poor health outcomes. • Most key medicines and commodities for EENC are available in hospitals. Only one in five hospitals has adequate sink handwashing facilities. Adequate hand hygiene6 practised in 82% of deliveries 48% of hospitals have alcohol gel/hand rub available in all delivery, recovery, postnatal and neonatal care rooms 20% of hospitals have adequate sink handwashing facilities5 in all delivery, recovery, postnatal and neonatal care rooms 72% of hospitals have clean and dry newborn resuscitation areas PRETERM BABIES, 20164 NEWBORN CARE PRACTICES * Women of 24–34 weeks of gestational age 11 11 Magnesium sulfate 100 60 33 23 10 0 20 40 60 80 100 Percentage of postpartum mothers Data from interviews and chart reviews of postpartum mothers: – 38 at national hospitals (n = 4) and – 173 at subnational hospitals (n = 21) 84 84 Encouraged to eat and drink during labour 89 73Syphilis testing recorded 6With companion during childbirth 11 11Episiotomy 95 100Oxytocin injected within 1 min of birth9 61 60Partographs completed correctly national hospital subnational hospital 91 Not in supine position during active labour ANTENATAL CARE AND DELIVERY PRACTICES, 20164 97 11 Percentage COVERAGE OF KEY INTERVENTIONS, 20157 0 20 40 60 80 100 99.6Skilled attendance at birth 99.6Facility delivery rate 24.8Births delivered by caesarean section 94.8Breastfeeding initiated within ≤ 1 hour of birth 95.4Women who received PNC* in ≤ 2 days of birth 98.4Newborns who received PNC* in ≤ 2 days of birth introduced in 53% of health facilities3 (49/93) 60% of staff coached (900/1493) 92% have EENC teams4 36% have established a quality improvement approach4,8 * postnatal care EENC 80% 92% 36% Of the facilities that have introduced EENC: EENC IMPLEMENTATION, 20173 Skin-to-skin contact no data Exclusive breastfeeding from 0 to 1 month no data 0 20 40 60 80 100 Percentage of term babies Data from interviews with postpartum mothers: – 40 at national hospitals (n = 4), and – 173 at subnational hospitals (n = 21) Prolonged (≥ 90 min) skin-to-skin contact Immediate skin-to-skin contact Sustained skin-to-skin contact until first breastfeed Received early and exclusive breastfeeding Bathed in > 24 hours 52 0Skin-to-skin contact applied in C-section deliveries national hospital subnational hospital TERM BABIES, 20164 68 58 63 62 88 81 38 48 77 56 Early EssEntial nEwborn CarE (EEnC) 2017 PROGRAMME READINESS FOR EENC SCALE-UP 20173 0 10 20 30 40 50 60 W PR /2 01 7/ DN H/ 01 1 – © W or ld H ea lth O rg an iza tio n 20 17 – S om e rig ht s re se rv ed . T hi s w or k is av ai la bl e un de r t he C C BY -N C- SA 3 .0 IG O li ce ns e. 62 second BIENNIAL PROGRESS REPORT (2016–2017) MONGOLIA (2) early essential neWBorn care MONGOLIA NEONATAL MORTALITY RATE 1 1990 2015 2020 30 10 5 Neonatal deaths (per 1000 live births) Target in national EENC 5-year action plan CAUSES OF NEONATAL DEATH, 20162 Preterm 30% Sepsis/ Pneumonia 18% Asphyxia 22% Congenital anomalies 23% Other 7% Detailed 12-month EENC implementation plan developed and funded EENC technical working group formed 1. Level and Trends in Child Mortality: Report 2017. UNICEF, 2017. Mongolia Health Indicators, 2015. 2. WHO Global Health Observatory Data, 2018. 3. Ministry of Health of Mongolia, 2017. 4. Based on data from assessments of the 25 national and first-level referral hospitals that have introduced EENC. 5. Adequate handwashing facilities defined as having at least one sink in the room, and all sinks in the room having running water, soap, and single-use towels available. 6. Adequate hand hygiene comprises washing hands twice before gloving and using sterile gloves to cut the umbilical cord. 7. Mongolia Health Indicators, 2015. Social Indicator Sample Survey. National Statistics Office of Mongolia, UNFPA, UNICEF, 2013. 8. Quality improvement approach consists of: (1) regular and documented meetings of the EENC team, (2) at least two EENC assessments per year, and (3) developing and updating an EENC hospital action plan at least quarterly. 9. Data from observations of 24 deliveries in 4 national hospitals and 85 deliveries in 18 subnational hospitals. PARTIAL EENC included in pre-service curricula (medical, midwifery and nursing) EENC 5-year action plan developed, costed and adopted Clinical intra-partum and newborn care protocol adapted, reviewed and endorsed YES NO STOCK-OUTS OF KEY MEDICINES AND COMMODITIES FOR EENC IN THE PAST 12 MONTHS, 20164 Antibiotics for sepsis Vitamin K Corticosteroids Oxytocin Functional bag and mask within 2 m of delivery beds Hepatitis B vaccine 0 1 2–4 > 4 Number of stock-outs across 25 hospitals (4 national hospitals and 21 subnational hospitals) 0 20 40 60 80 100 Percentage of preterm babies Data from interviews and chart reviews of postpartum mothers: – 27 at national hospitals (n = 4), and – 45 at subnational hospitals (n = 19) Data from observations in 25 hospitals (4 national hospitals and 21 subnational hospitals) 60 88 Pregnant women* at risk of preterm labour receiving corticosteroids 48 40Immediate skin-to-skin contact 11Prolonged (≥ 90 min) skin-to-skin contact 53 44Sustained skin-to-skin contact until first breastfeed national hospital subnational hospital Pregnant women < 32 weeks of gestational age receiving MgSO4 Received Kangaroo Mother Care Received early and exclusive breastfeeding ENVIRONMENTAL HYGIENE, 20164 KEY POINTS • 50% of all under-5 deaths in Mongolia now occur in the newborn period. • EENC coaching has begun in 4/4 national and 21/21 first-level referral government hospitals and in 23/113 first-level facilities. • Seventy-four per cent of staff at national and 84% at first-level referral hospitals have been coached in EENC. • The majority of pregnant women have syphilis testing recorded, are encouraged to eat and drink, assume a non-supine position during the active stage of labour, and are injected with oxytocin within 1 minute of birth. However, less than 10% have a companion at childbirth. • Preterm newborns are less likely to receive EENC, which puts them at higher risk of poor health outcomes. • Most key medicines and commodities for EENC are available in hospitals. Only one in five hospitals has adequate sink handwashing facilities. Adequate hand hygiene6 practised in 82% of deliveries 48% of hospitals have alcohol gel/hand rub available in all delivery, recovery, postnatal and neonatal care rooms 20% of hospitals have adequate sink handwashing facilities5 in all delivery, recovery, postnatal and neonatal care rooms 72% of hospitals have clean and dry newborn resuscitation areas PRETERM BABIES, 20164 NEWBORN CARE PRACTICES * Women of 24–34 weeks of gestational age 11 11 Magnesium sulfate 100 60 33 23 10 0 20 40 60 80 100 Percentage of postpartum mothers Data from interviews and chart reviews of postpartum mothers: – 38 at national hospitals (n = 4) and – 173 at subnational hospitals (n = 21) 84 84 Encouraged to eat and drink during labour 89 73Syphilis testing recorded 6With companion during childbirth 11 11Episiotomy 95 100Oxytocin injected within 1 min of birth9 61 60Partographs completed correctly national hospital subnational hospital 91 Not in supine position during active labour ANTENATAL CARE AND DELIVERY PRACTICES, 20164 97 11 Percentage COVERAGE OF KEY INTERVENTIONS, 20157 0 20 40 60 80 100 99.6Skilled attendance at birth 99.6Facility delivery rate 24.8Births delivered by caesarean section 94.8Breastfeeding initiated within ≤ 1 hour of birth 95.4Women who received PNC* in ≤ 2 days of birth 98.4Newborns who received PNC* in ≤ 2 days of birth introduced in 53% of health facilities3 (49/93) 60% of staff coached (900/1493) 92% have EENC teams4 36% have established a quality improvement approach4,8 * postnatal care EENC 80% 92% 36% Of the facilities that have introduced EENC: EENC IMPLEMENTATION, 20173 Skin-to-skin contact no data Exclusive breastfeeding from 0 to 1 month no data 0 20 40 60 80 100 Percentage of term babies Data from interviews with postpartum mothers: – 40 at national hospitals (n = 4), and – 173 at subnational hospitals (n = 21) Prolonged (≥ 90 min) skin-to-skin contact Immediate skin-to-skin contact Sustained skin-to-skin contact until first breastfeed Received early and exclusive breastfeeding Bathed in > 24 hours 52 0Skin-to-skin contact applied in C-section deliveries national hospital subnational hospital TERM BABIES, 20164 68 58 63 62 88 81 38 48 77 56 Early EssEntial nEwborn CarE (EEnC) 2017 PROGRAMME READINESS FOR EENC SCALE-UP 20173 0 10 20 30 40 50 60 W PR /2 01 7/ DN H/ 01 1 – © W or ld H ea lth O rg an iza tio n 20 17 – S om e rig ht s re se rv ed . T hi s w or k is av ai la bl e un de r t he C C BY -N C- SA 3 .0 IG O li ce ns e. 63 early essential neWBorn care PAPUA NEW GUINEA (1) 0 20 40 60 80 100 Percentage of term babies Data from interviews with postpartum mothers: – 10 at national hospital (n = 1), and – 39 at subnational hospitals (n = 5) 0 3 Prolonged (≥ 90 min) skin-to-skin contact 10 44Immediate skin-to-skin contact 40 46 Sustained skin-to-skin contact until first breastfeed 90 62 Received early and exclusive breastfeeding 8 no data Bathed in > 24 hours 50 no dataSkin-to-skin contact applied in C-section deliveries national hospital subnational hospital TERM BABIES, 20164 PA UA EW GUINEA NEONATAL MORTALITY RATE 1 1990 2006 2020 31 29 10 Neonatal deaths (per 1000 live births) Target in regional action plan CAUSES OF NEONATAL DEATH, 20162 Preterm 30% Sepsis/ Pneumonia 23% Asphyxia 28% Congenital anomalies 11% Other 7% Diarrhoea 1% PROGRAMME READINESS FOR EENC SCALE-UP 20173 Detailed 12-month EENC implementation plan developed and funded EENC technical working group formed 1. Level and Trends in Child Mortality: Report 2017. UNICEF, 2017. Papua New Guinea Demographic and Health Survey, 2006. 2. WHO Global Health Observatory Data, 2018. 3. National Department of Health, 2017. 4. Assessments of 6 hospitals that have introduced EENC, 2016. 5. Adequate handwashing facilities defined as having at least one sink in the room, and all sinks in the room having running water, soap, and single-use towels/re-usable sterile towels/hand dryers available. 6. Adequate hand hygiene comprises washing hands twice before gloving and using sterile gloves to cut the umbilical cord. 7. Papua New Guinea Demographic and Health Survey, 2006. 8. Data from the national hospital. An additional 579 staff have been coached in subnational health facilities. 9. Applies to national and first-level referral hospitals only. 10. Quality improvement approach consists of: (1) regular and documented meetings of the EENC team, (2) at least two EENC assessments per year, and (3) developing and updating an EENC hospital action plan at least quarterly. 11. Data from observations of 5 deliveries at the national hospital and 9 deliveries at 4 subnational hospitals. PARTIAL EENC included in pre-service curricula (medical, midwifery and nursing) EENC 5-year action plan developed, costed and adopted Clinical intra-partum and newborn care protocol adapted, reviewed and endorsed YES NO STOCK-OUTS OF KEY MEDICINES AND COMMODITIES FOR EENC IN THE PAST 12 MONTHS, 20164 Antibiotics for sepsis Vitamin K Corticosteroids Magnesium sulfate Oxytocin 0 1 2–4 > 4 Number of stock-outs across 6 hospitals (1 national hospital and 5 subnational hospitals) 0 20 40 60 80 100 Percentage of preterm babies No data from interviews and chart reviews of postpartum mothers Data from observations in 6 hospitals (1 national hospital and 5 subnational hospitals) Pregnant women* at risk of preterm labour receiving corticosteroids Immediate skin-to-skin contact Prolonged (≥ 90 min) skin-to-skin contact Sustained skin-to-skin contact until first breastfeed national hospital subnational hospital Pregnant women < 32 weeks of gestational age receiving MgSO4 Received Kangaroo Mother Care Received early and exclusive breastfeeding ENVIRONMENTAL HYGIENE, 20164 KEY POINTS • 42% of all under-5 deaths in PNG now occur in the newborn period. • EENC has been introduced in the national hospital, 18/31 (58%) first level referral hospitals and 173/717 (24%) first-level facilities. • Seventy per cent of staff at the national hospital have been coached in EENC. • All women receive oxytocin within 1 minute of birth at the national hospital, where episiotomies are also not routinely performed. Sub- national hospitals perform relatively higher than the national hospital for other antenatal and delivery practices. • Data on care for preterm babies are not available. • Most key medicines and commodities for EENC are available at na- tional and subnational hospitals. However, no hospital has adequate sink handwashing facilities. Adequate hand hygiene6 practised in 7% of deliveries Hospitals have alcohol gel/hand rub available in all delivery, recovery, postnatal and neonatal care rooms: no data 0% of hospitals have adequate sink handwashing facilities5 in all delivery, recovery, postnatal and neonatal care rooms 100% of hospitals have clean and dry newborn resuscitation areas PRETERM BABIES, 20164 NEWBORN CARE PRACTICES * Women of 24–34 weeks of gestational age Functional bag and mask within 2 m of delivery beds Hepatitis B vaccine no data no data no data no data no data no data no data introduced in 29% of health facilities (194/671) 70% of staff coached8 (135/192) 3% have EENC teams9 3% have established a quality improvement approach9,10 EENC 70% 3% 3% Of the facilities that have introduced EENC: EENC IMPLEMENTATION, 20173 0 20 40 60 80 100 Percentage of postpartum mothers Data from interviews and chart reviews of postpartum mothers: – 10 at national hospital (n = 1) and – 39 at subnational hospitals (n = 5) Encouraged to eat and drink during labour Syphilis testing recorded With companion during childbirth Episiotomy Oxytocin injected within 1 min of birth11 Partographs completed correctly national hospital subnational hospital Not in supine position during active labour ANTENATAL CARE AND DELIVERY PRACTICES, 20164 40 68 50 64 71 20 23 0 67 100 55 30 68 60 Percentage COVERAGE OF KEY INTERVENTIONS, 20147 0 20 40 60 80 100 53Skilled attendance at birth 0 0 0 Facility delivery rate Births delivered by caesarean section Breastfeeding initiated within ≤ 1 hour of birth Women who received PNC* in ≤ 2 days of birth Newborns who received PNC* in ≤ 2 days of birth * postnatal care Skin-to-skin contact no data Exclusive breastfeeding from 0 to 1 month 80 0 Early EssEntial nEwborn CarE (EEnC) 2017 52 0 10 20 30 40 50 60 W PR /2 01 7/ DN H/ 01 2 – © W or ld H ea lth O rg an iza tio n 20 17 – S om e rig ht s re se rv ed . T hi s w or k is av ai la bl e un de r t he C C BY -N C- SA 3 .0 IG O li ce ns e. 64 second BIENNIAL PROGRESS REPORT (2016–2017) PAPUA NEW GUINEA (2) early essential neWBorn care 0 20 40 60 80 100 Percentage of term babies Data from interviews with postpartum mothers: – 10 at national hospital (n = 1), and – 39 at subnational hospitals (n = 5) 0 3 Prolonged (≥ 90 min) skin-to-skin contact 10 44Immediate skin-to-skin contact 40 46 Sustained skin-to-skin contact until first breastfeed 90 62 Received early and exclusive breastfeeding 8 no data Bathed in > 24 hours 50 no dataSkin-to-skin contact applied in C-section deliveries national hospital subnational hospital TERM BABIES, 20164 PAPUA NEW GUINEA NEONATAL MORTALITY RATE 1 1990 2006 2020 31 29 10 Neonatal deaths (per 1000 live births) Target in regional action plan CAUSES OF NEONATAL DEATH, 20162 Preterm 30% Sepsis/ Pneumonia 23% Asphyxia 28% Congenital anomalies 11% Other 7% Diarrhoea 1% PROGRAMME READINESS FOR EENC SCALE-UP 20173 Detailed 12-month EENC implementation plan developed and funded EENC technical working group formed 1. Level and Trends in Child Mortality: Report 2017. UNICEF, 2017. Papua New Guinea Demographic and Health Survey, 2006. 2. WHO Global Health Observatory Data, 2018. 3. National Department of Health, 2017. 4. Assessments of 6 hospitals that have introduced EENC, 2016. 5. Adequate handwashing facilities defined as having at least one sink in the room, and all sinks in the room having running water, soap, and single-use towels/re-usable sterile towels/hand dryers available. 6. Adequate hand hygiene comprises washing hands twice before gloving and using sterile gloves to cut the umbilical cord. 7. Papua New Guinea Demographic and Health Survey, 2006. 8. Data from the national hospital. An additional 579 staff have been coached in subnational health facilities. 9. Applies to national and first-level referral hospitals only. 10. Quality improvement approach consists of: (1) regular and documented meetings of the EENC team, (2) at least two EENC assessments per year, and (3) developing and updating an EENC hospital action plan at least quarterly. 11. Data from observations of 5 deliveries at the national hospital and 9 deliveries at 4 subnational hospitals. PARTIAL EENC included in pre-service curricula (medical, midwifery and nursing) EENC 5-year action plan developed, costed and adopted Clinical intra-partum and newborn care protocol adapted, reviewed and endorsed YES NO STOCK-OUTS OF KEY MEDICINES AND COMMODITIES FOR EENC IN THE PAST 12 MONTHS, 20164 Antibiotics for sepsis Vitamin K Corticosteroids Magnesium sulfate Oxytocin 0 1 2–4 > 4 Number of stock-outs across 6 hospitals (1 national hospital and 5 subnational hospitals) 0 20 40 60 80 100 Percentage of preterm babies No data from interviews and chart reviews of postpartum mothers Data from observations in 6 hospitals (1 national hospital and 5 subnational hospitals) Pregnant women* at risk of preterm labour receiving corticosteroids Immediate skin-to-skin contact Prolonged (≥ 90 min) skin-to-skin contact Sustained skin-to-skin contact until first breastfeed national hospital subnational hospital Pregnant women < 32 weeks of gestational age receiving MgSO4 Received Kangaroo Mother Care Received early and exclusive breastfeeding ENVIRONMENTAL HYGIENE, 20164 KEY POINTS • 42% of all under-5 deaths in PNG now occur in the newborn period. • EENC has been introduced in the national hospital, 18/31 (58%) first level referral hospitals and 173/717 (24%) first-level facilities. • Seventy per cent of staff at the national hospital have been coached in EENC. • All women receive oxytocin within 1 minute of birth at the national hospital, where episiotomies are also not routinely performed. Sub- national hospitals perform relatively higher than the national hospital for other antenatal and delivery practices. • Data on care for preterm babies are not available. • Most key medicines and commodities for EENC are available at na- tional and subnational hospitals. However, no hospital has adequate sink handwashing facilities. Adequate hand hygiene6 practised in 7% of deliveries Hospitals have alcohol gel/hand rub available in all delivery, recovery, postnatal and neonatal care rooms: no data 0% of hospitals have adequate sink handwashing facilities5 in all delivery, recovery, postnatal and neonatal care rooms 100% of hospitals have clean and dry newborn resuscitation areas PRETERM BABIES, 20164 NEWBORN CARE PRACTICES * Women of 24–34 weeks of gestational age Functional bag and mask within 2 m of delivery beds Hepatitis B vaccine no data no data no data no data no data no data no data introduced in 29% of health facilities (194/671) 70% of staff coached8 (135/192) 3% have EENC teams9 3% have established a quality improvement approach9,10 EENC 70% 3% 3% Of the facilities that have introduced EENC: EENC IMPLEMENTATION, 20173 0 20 40 60 80 100 Percentage of postpartum mothers Data from interviews and chart reviews of postpartum mothers: – 10 at national hospital (n = 1) and – 39 at subnational hospitals (n = 5) Encouraged to eat and drink during labour Syphilis testing recorded With companion during childbirth Episiotomy Oxytocin injected within 1 min of birth11 Partographs completed correctly national hospital subnational hospital Not in supine position during active labour ANTENATAL CARE AND DELIVERY PRACTICES, 20164 40 68 50 64 71 20 23 0 67 100 55 30 68 60 Percentage COVERAGE OF KEY INTERVENTIONS, 20147 0 20 40 60 80 100 53Skilled attendance at birth 0 0 0 Facility delivery rate Births delivered by caesarean section Breastfeeding initiated within ≤ 1 hour of birth Women who received PNC* in ≤ 2 days of birth Newborns who received PNC* in ≤ 2 days of birth * postnatal care Skin-to-skin contact no data Exclusive breastfeeding from 0 to 1 month 80 0 Early EssEntial nEwborn CarE (EEnC) 2017 52 0 10 20 30 40 50 60 W PR /2 01 7/ DN H/ 01 2 – © W or ld H ea lth O rg an iza tio n 20 17 – S om e rig ht s re se rv ed . T hi s w or k is av ai la bl e un de r t he C C BY -N C- SA 3 .0 IG O li ce ns e. 65 early essential neWBorn care PHILIPPINES (1)ILI PINES NEONATAL MORTALITY RATE 1 2003 2013 2020 17 13 10 Neonatal deaths (per 1000 live births) Target in regional action plan CAUSES OF NEONATAL DEATH, 20162 Preterm 31% Sepsis/ Pneumonia 19% Asphyxia 24% Congenital anomalies 17% Other 8% Diarrhoea 1% PROGRAMME READINESS FOR EENC SCALE-UP 20173 Detailed 12-month EENC implementation plan developed and funded EENC technical working group formed 1. National Demographic and Health Survey Philippines, 2003 and 2013. 2. WHO Global Health Observatory, 2018. 3. Department of Health of the Philippines, 2017. 4. Based on data from assessments of 28 randomly selected hospitals that have introduced EINC, 2017. 5. Adequate handwashing facilities defined as having at least one sink in the room, and all sinks in the room having running water, soap, and single-use towels/re-usable sterile towels/hand dryers available. 6. Adequate hand hygiene comprises washing hands twice before gloving and using sterile gloves to cut the umbilical cord. 7. National Demographic and Health Survey Philippines, 2013. 8. Quality improvement approach consists of: (1) regular and documented meetings of the EENC team, (2) at least two EENC assessments per year, and (3) developing and updating an EENC hospital action plan at least quarterly. 9. Data from observations of 78 deliveries at 13 national hospitals and 52 deliveries at 14 subnational hospitals. PARTIAL EENC included in pre-service curricula (medical, midwifery and nursing) EENC 5-year action plan developed, costed and adopted Clinical intra-partum and newborn care protocol adapted, reviewed and endorsed YES NO STOCK-OUTS OF KEY MEDICINES AND COMMODITIES FOR EENC IN THE PAST 12 MONTHS, 20174 Antibiotics for sepsis Vitamin K Corticosteroids 0 1 2–4 > 4 Number of stock-outs across 28 hospitals (13 national hospitals and 15 subnational hospitals) 0 20 40 60 80 100 Percentage of preterm babies Data from interviews and chart reviews of postpartum mothers: – 102 at national hospitals (n = 13), and – 42 at subnational hospitals (n = 12) Data from observations in 28 hospitals (13 national hospitals and 15 subnational hospitals) 70 64 Pregnant women* at risk of preterm labour receiving corticosteroids 59 60Immediate skin-to-skin contact 4Prolonged (≥ 90 min) skin-to-skin contact 17 18Sustained skin-to-skin contact until first breastfeed national hospital subnational hospital Pregnant women < 32 weeks of gestational age receiving MgSO4 Received Kangaroo Mother Care Received early and exclusive breastfeeding 17 ENVIRONMENTAL HYGIENE, 20174 KEY POINTS • 42% of all under-5 deaths in Philippines now occur in the newborn period. • Essential intrapartum and newborn care (EINC) was rolled out in 2010. Since, at least 104 national and regional and 324 first-level referral hospitals have introduced EINC. • The majority of pregnant women are encouraged to assume a non- supine position during active labour. Other globally recommended intrapartum care practices are practised for around half or less of pregnant women. • Preterms are less likely to receive EENC, which puts them at higher risk of poor health outcomes. • Stock-outs of key medicines and commodities are observed more frequently in national and regional hospitals. • A low proportion of hospitals has adequate sink handwashing facilities in all maternal and neonatal care rooms. Appropriate hand hygiene is practised in one out of two deliveries. Adequate hand hygiene6 practised in 48% of deliveries 21% of hospitals have alcohol gel/hand rub available in all delivery, recovery, postnatal and neonatal care rooms 7% of hospitals have adequate sink handwashing facilities5 in all delivery, recovery, postnatal and neonatal care rooms 93% of hospitals have clean and dry newborn resuscitation areas PRETERM BABIES, 20174 NEWBORN CARE PRACTICES * Women of 24–34 weeks of gestational age 14 57 Magnesium sulfate Oxytocin Functional bag and mask within 2 m of delivery beds Hepatitis B vaccine 33 13 21 45 0 20 40 60 80 100 Percentage of postpartum mothers Data from interviews and chart reviews of postpartum mothers: – 113 at national hospitals (n = 13) and – 141 at subnational hospitals (n = 15) 45 76 59 Encouraged to eat and drink during labour 31 18Syphilis testing recorded 43With companion during childbirth 29 29Episiotomy 27 68Oxytocin injected within 1 min of birth9 24 24Partographs completed correctly national hospital subnational hospital 73 Not in supine position during active labour ANTENATAL CARE AND DELIVERY PRACTICES, 20174 76 24 Percentage COVERAGE OF KEY INTERVENTIONS, 20137 0 20 40 60 80 100 73Skilled attendance at birth 61Facility delivery rate 9Births delivered by caesarean section 50Breastfeeding initiated within ≤ 1 hour of birth 72Women who received PNC* in ≤ 2 days of birth 53Newborns who received PNC* in ≤ 2 days of birth introduced in 78% of health facilities (1093/1401) 43% of staff coached (1676/3934) 75% have EENC teams4 36% have established a quality improvement approach8 * postnatal care EENC 43% 75% 36% Of the facilities that have introduced EENC4: EENC IMPLEMENTATION, 20173 Skin-to-skin contact Exclusive breastfeeding from 0 to 1 month 90 64 0 20 40 60 80 100 Percentage of term babies Data from interviews with postpartum mothers: – 131 at national hospitals (n = 13), and – 141 at subnational hospitals (n = 15) Prolonged (≥ 90 min) skin-to-skin contact Immediate skin-to-skin contact Sustained skin-to-skin contact until first breastfeed Received early and exclusive breastfeeding Bathed in > 24 hours 48 6Skin-to-skin contact applied in C-section deliveries national hospital subnational hospital TERM BABIES, 20174 35 29 69 65 59 36 62 55 47 92 Early EssEntial nEwborn CarE (EEnC) 2017 0 10 20 30 40 50 60 W PR /2 01 7/ DN H/ 00 8 – © W or ld H ea lth O rg an iza tio n 20 17 – S om e rig ht s re se rv ed . T hi s w or k is av ai la bl e un de r t he C C BY -N C- SA 3 .0 IG O li ce ns e. 66 second BIENNIAL PROGRESS REPORT (2016–2017) PHILIPPINES (2) early essential neWBorn care PHILIPPINES NEONATAL MORTALITY RATE 1 2003 2013 2020 17 13 10 Neonatal deaths (per 1000 live births) Target in regional action plan CAUSES OF NEONATAL DEATH, 20162 Preterm 31% Sepsis/ Pneumonia 19% Asphyxia 24% Congenital anomalies 17% Other 8% Diarrhoea 1% PROGRAMME READINESS FOR EENC SCALE-UP 20173 Detailed 12-month EENC implementation plan developed and funded EENC technical working group formed 1. National Demographic and Health Survey Philippines, 2003 and 2013. 2. WHO Global Health Observatory, 2018. 3. Department of Health of the Philippines, 2017. 4. Based on data from assessments of 28 randomly selected hospitals that have introduced EINC, 2017. 5. Adequate handwashing facilities defined as having at least one sink in the room, and all sinks in the room having running water, soap, and single-use towels/re-usable sterile towels/hand dryers available. 6. Adequate hand hygiene comprises washing hands twice before gloving and using sterile gloves to cut the umbilical cord. 7. National Demographic and Health Survey Philippines, 2013. 8. Quality improvement approach consists of: (1) regular and documented meetings of the EENC team, (2) at least two EENC assessments per year, and (3) developing and updating an EENC hospital action plan at least quarterly. 9. Data from observations of 78 deliveries at 13 national hospitals and 52 deliveries at 14 subnational hospitals. PARTIAL EENC included in pre-service curricula (medical, midwifery and nursing) EENC 5-year action plan developed, costed and adopted Clinical intra-partum and newborn care protocol adapted, reviewed and endorsed YES NO STOCK-OUTS OF KEY MEDICINES AND COMMODITIES FOR EENC IN THE PAST 12 MONTHS, 20174 Antibiotics for sepsis Vitamin K Corticosteroids 0 1 2–4 > 4 Number of stock-outs across 28 hospitals (13 national hospitals and 15 subnational hospitals) 0 20 40 60 80 100 Percentage of preterm babies Data from interviews and chart reviews of postpartum mothers: – 102 at national hospitals (n = 13), and – 42 at subnational hospitals (n = 12) Data from observations in 28 hospitals (13 national hospitals and 15 subnational hospitals) 70 64 Pregnant women* at risk of preterm labour receiving corticosteroids 59 60Immediate skin-to-skin contact 4Prolonged (≥ 90 min) skin-to-skin contact 17 18Sustained skin-to-skin contact until first breastfeed national hospital subnational hospital Pregnant women < 32 weeks of gestational age receiving MgSO4 Received Kangaroo Mother Care Received early and exclusive breastfeeding 17 ENVIRONMENTAL HYGIENE, 20174 KEY POINTS • 42% of all under-5 deaths in Philippines now occur in the newborn period. • Essential intrapartum and newborn care (EINC) was rolled out in 2010. Since, at least 104 national and regional and 324 first-level referral hospitals have introduced EINC. • The majority of pregnant women are encouraged to assume a non- supine position during active labour. Other globally recommended intrapartum care practices are practised for around half or less of pregnant women. • Preterms are less likely to receive EENC, which puts them at higher risk of poor health outcomes. • Stock-outs of key medicines and commodities are observed more frequently in national and regional hospitals. • A low proportion of hospitals has adequate sink handwashing facilities in all maternal and neonatal care rooms. Appropriate hand hygiene is practised in one out of two deliveries. Adequate hand hygiene6 practised in 48% of deliveries 21% of hospitals have alcohol gel/hand rub available in all delivery, recovery, postnatal and neonatal care rooms 7% of hospitals have adequate sink handwashing facilities5 in all delivery, recovery, postnatal and neonatal care rooms 93% of hospitals have clean and dry newborn resuscitation areas PRETERM BABIES, 20174 NEWBORN CARE PRACTICES * Women of 24–34 weeks of gestational age 14 57 Magnesium sulfate Oxytocin Functional bag and mask within 2 m of delivery beds Hepatitis B vaccine 33 13 21 45 0 20 40 60 80 100 Percentage of postpartum mothers Data from interviews and chart reviews of postpartum mothers: – 113 at national hospitals (n = 13) and – 141 at subnational hospitals (n = 15) 45 76 59 Encouraged to eat and drink during labour 31 18Syphilis testing recorded 43With companion during childbirth 29 29Episiotomy 27 68Oxytocin injected within 1 min of birth9 24 24Partographs completed correctly national hospital subnational hospital 73 Not in supine position during active labour ANTENATAL CARE AND DELIVERY PRACTICES, 20174 76 24 Percentage COVERAGE OF KEY INTERVENTIONS, 20137 0 20 40 60 80 100 73Skilled attendance at birth 61Facility delivery rate 9Births delivered by caesarean section 50Breastfeeding initiated within ≤ 1 hour of birth 72Women who received PNC* in ≤ 2 days of birth 53Newborns who received PNC* in ≤ 2 days of birth introduced in 78% of health facilities (1093/1401) 43% of staff coached (1676/3934) 75% have EENC teams4 36% have established a quality improvement approach8 * postnatal care EENC 43% 75% 36% Of the facilities that have introduced EENC4: EENC IMPLEMENTATION, 20173 Skin-to-skin contact Exclusive breastfeeding from 0 to 1 month 90 64 0 20 40 60 80 100 Percentage of term babies Data from interviews with postpartum mothers: – 131 at national hospitals (n = 13), and – 141 at subnational hospitals (n = 15) Prolonged (≥ 90 min) skin-to-skin contact Immediate skin-to-skin contact Sustained skin-to-skin contact until first breastfeed Received early and exclusive breastfeeding Bathed in > 24 hours 48 6Skin-to-skin contact applied in C-section deliveries national hospital subnational hospital TERM BABIES, 20174 35 29 69 65 59 36 62 55 47 92 Early EssEntial nEwborn CarE (EEnC) 2017 0 10 20 30 40 50 60 W PR /2 01 7/ DN H/ 00 8 – © W or ld H ea lth O rg an iza tio n 20 17 – S om e rig ht s re se rv ed . T hi s w or k is av ai la bl e un de r t he C C BY -N C- SA 3 .0 IG O li ce ns e. 67 early essential neWBorn care SOLOMON ISLANDS (1)SOLO N ISLANDS NEONATAL MORTALITY RATE 1 1990 2007 2015 2020 15 15 9 10 Neonatal deaths (per 1000 live births) Target in regional action plan CAUSES OF NEONATAL DEATH, 20162 Preterm 31% Sepsis/ Pneumonia 21% Asphyxia 23% Congenital anomalies 18% Other 7% PROGRAMME READINESS FOR EENC SCALE-UP 20173 Detailed 12-month EENC implementation plan developed and funded EENC technical working group formed 1. Level and Trends in Child Mortality: Report 2017. UNICEF, 2017. Solomon Islands Demographic and Health Surveys, 2007 and 2015. 2. WHO Global Health Observatory Data, 2015. 3. Ministry of Health and Medical Services, 2017. 4. Assessments of 10 health facilities that have introduced EENC, 2017. 5. Adequate handwashing facilities defined as having at least one sink in the room, and all sinks in the room having running water, soap, and single-use towels/re-usable sterile towels/hand dryers available. 6. Adequate hand hygiene comprises washing hands twice before gloving and using sterile gloves to cut the umbilical cord. 7. Solomon Islands Demographic and Health Survey, 2015. 8. Applies to national and first-level referral hospitals only. 9. Quality improvement approach consists of: regular and documented meetings of the EENC team, (2) at least two EENC assessments per year, and (3) developing and updating an EENC hospital action plan at least quarterly. 10. Data from observations of 2 deliveries at 2 subnational hospitals. PARTIAL EENC included in pre-service curricula (medical, midwifery and nursing) EENC 5-year action plan developed, costed and adopted Clinical intra-partum and newborn care protocol adapted, reviewed and endorsed YES NO STOCK-OUTS OF KEY MEDICINES AND COMMODITIES FOR EENC IN THE PAST 12 MONTHS, 20174 Antibiotics for sepsis Vitamin K Corticosteroids Magnesium sulfate Oxytocin Hepatitis B vaccine 0 1 2–4 > 4 Number of stock-outs across 10 health facilities (1 national hospital and 9 subnational health facilities) 0 20 40 60 80 100 Percentage of preterm babies Data from interviews and chart reviews of postpartum mothers: – 7 at national hospitals (n = 1), and – 2 at subnational hospitals (n = 2) Data from observations in 10 health facilities (1 national hospital and 9 subnational health facilities) Pregnant women* at risk of preterm labour receiving corticosteroids 86 100Immediate skin-to-skin contact 100 14Prolonged (≥ 90 min) skin-to-skin contact 100 14Sustained skin-to-skin contact until first breastfeed national hospital subnational hospital Pregnant women < 32 weeks of gestational age receiving MgSO4 0 0 Received Kangaroo Mother Care 0 50 Received early and exclusive breastfeeding ENVIRONMENTAL HYGIENE, 20174 KEY POINTS • 43% of all under-5 deaths in Solomon Islands now occur in the new- born period. • EENC has been introduced in the national hospital, 6/9 (67%) provincial hospitals, and 138/292 (47%) first-level health facilities. Almost all staff providing childbirth and newborn at the national hospital have been coached in EENC. Coaching coverage at provincial hospitals is 41% and in first level facilities, 54%. • Most mothers are encouraged to eat and drink and assume a non- supine position during active labour, and have a companion at the time of childbirth. Injection of oxytocin within 1 minute of birth however, is only done for half of the mothers in subnational health facilities. • Preterm babies are less likely to receive EENC, which places them at higher risk of poor health outcomes. • Stock-outs of key medicines and commodities for EENC are more frequently experienced in subnational health facilities. • No health facility has adequate sink handwashing facilities in mater- nal and neonatal care rooms. Adequate hand hygiene6 practised in deliveries: no data 20% of health facilities have alcohol gel/hand rub available in all delivery, recovery, postnatal and neonatal care rooms 0% of health facilities have adequate sink handwashing facilities5 in all delivery, recovery, postnatal and neonatal care rooms 100% of health facilities have clean and dry newborn resuscitation areas PRETERM BABIES, 20174 NEWBORN CARE PRACTICES * Women of 24–34 weeks of gestational age Functional bag and mask within 2 m of delivery beds 0 20 40 60 80 100 Percentage of postpartum mothers Data from interviews and chart reviews of postpartum mothers: – 10 at national hospitals (n = 1) and – 33 at subnational health facilities (n = 9) 70 76 82 Encouraged to eat and drink during labour 30 15Syphilis testing recorded 91With companion during childbirth 27 0Episiotomy 50 no dataOxytocin injected within 1 min of birth10 42 100Partographs completed correctly national hospital subnational hospital 94 Not in supine position during active labour ANTENATAL CARE AND DELIVERY PRACTICES, 20174 80 60 Percentage COVERAGE OF KEY INTERVENTIONS, 20157 0 20 40 60 80 100 86Skilled attendance at birth 85Facility delivery rate 6Births delivered by caesarean section 79Breastfeeding initiated within ≤ 1 hour of birth 69Women who received PNC* in ≤ 2 days of birth 16Newborns who received PNC* in ≤ 2 days of birth introduced in 48% of health facilities (145/302) 58% of staff coached (408/710) 13% have EENC teams8 0% have established a quality improvement approach8,9 * postnatal care EENC 58% 13% 0% Of the facilities that have introduced EENC: EENC IMPLEMENTATION, 20173 Skin-to-skin contact no data Exclusive breastfeeding from 0 to 1 month 87 0 20 40 60 80 100 Percentage of term babies Data from interviews with postpartum mothers: – 10 at national hospital (n = 1), and – 33 at subnational health facilities (n = 9) 80 64 Prolonged (≥ 90 min) skin-to-skin contact 70 70Immediate skin-to-skin contact 80 70 Sustained skin-to-skin contact until first breastfeed 90 55 Received early and exclusive breastfeeding 50 67Bathed in > 24 hours 67 0Skin-to-skin contact applied in C-section deliveries national hospital subnational hospital TERM BABIES, 20174 I 14 no data Early EssEntial nEwborn CarE (EEnC) 2017 0 10 20 30 40 50 60 W PR /2 01 7/ DN H/ 01 3 – © W or ld H ea lth O rg an iza tio n 20 17 – S om e rig ht s re se rv ed . T hi s w or k is av ai la bl e un de r t he C C BY -N C- SA 3 .0 IG O li ce ns e. 68 second BIENNIAL PROGRESS REPORT (2016–2017) SOLOMON ISLANDS (2) early essential neWBorn care SOLOMON ISLANDS NEONATAL MORTALITY RATE 1 1990 2007 2015 2020 15 15 9 10 Neonatal deaths (per 1000 live births) Target in regional action plan CAUSES OF NEONATAL DEATH, 20162 Preterm 31% Sepsis/ Pneumonia 21% Asphyxia 23% Congenital anomalies 18% Other 7% PROGRAMME READINESS FOR EENC SCALE-UP 20173 Detailed 12-month EENC implementation plan developed and funded EENC technical working group formed 1. Level and Trends in Child Mortality: Report 2017. UNICEF, 2017. Solomon Islands Demographic and Health Surveys, 2007 and 2015. 2. WHO Global Health Observatory Data, 2015. 3. Ministry of Health and Medical Services, 2017. 4. Assessments of 10 health facilities that have introduced EENC, 2017. 5. Adequate handwashing facilities defined as having at least one sink in the room, and all sinks in the room having running water, soap, and single-use towels/re-usable sterile towels/hand dryers available. 6. Adequate hand hygiene comprises washing hands twice before gloving and using sterile gloves to cut the umbilical cord. 7. Solomon Islands Demographic and Health Survey, 2015. 8. Applies to national and first-level referral hospitals only. 9. Quality improvement approach consists of: regular and documented meetings of the EENC team, (2) at least two EENC assessments per year, and (3) developing and updating an EENC hospital action plan at least quarterly. 10. Data from observations of 2 deliveries at 2 subnational hospitals. PARTIAL EENC included in pre-service curricula (medical, midwifery and nursing) EENC 5-year action plan developed, costed and adopted Clinical intra-partum and newborn care protocol adapted, reviewed and endorsed YES NO STOCK-OUTS OF KEY MEDICINES AND COMMODITIES FOR EENC IN THE PAST 12 MONTHS, 20174 Antibiotics for sepsis Vitamin K Corticosteroids Magnesium sulfate Oxytocin Hepatitis B vaccine 0 1 2–4 > 4 Number of stock-outs across 10 health facilities (1 national hospital and 9 subnational health facilities) 0 20 40 60 80 100 Percentage of preterm babies Data from interviews and chart reviews of postpartum mothers: – 7 at national hospitals (n = 1), and – 2 at subnational hospitals (n = 2) Data from observations in 10 health facilities (1 national hospital and 9 subnational health facilities) Pregnant women* at risk of preterm labour receiving corticosteroids 86 100Immediate skin-to-skin contact 100 14Prolonged (≥ 90 min) skin-to-skin contact 100 14Sustained skin-to-skin contact until first breastfeed national hospital subnational hospital Pregnant women < 32 weeks of gestational age receiving MgSO4 0 0 Received Kangaroo Mother Care 0 50 Received early and exclusive breastfeeding ENVIRONMENTAL HYGIENE, 20174 KEY POINTS • 43% of all under-5 deaths in Solomon Islands now occur in the new- born period. • EENC has been introduced in the national hospital, 6/9 (67%) provincial hospitals, and 138/292 (47%) first-level health facilities. Almost all staff providing childbirth and newborn at the national hospital have been coached in EENC. Coaching coverage at provincial hospitals is 41% and in first level facilities, 54%. • Most mothers are encouraged to eat and drink and assume a non- supine position during active labour, and have a companion at the time of childbirth. Injection of oxytocin within 1 minute of birth however, is only done for half of the mothers in subnational health facilities. • Preterm babies are less likely to receive EENC, which places them at higher risk of poor health outcomes. • Stock-outs of key medicines and commodities for EENC are more frequently experienced in subnational health facilities. • No health facility has adequate sink handwashing facilities in mater- nal and neonatal care rooms. Adequate hand hygiene6 practised in deliveries: no data 20% of health facilities have alcohol gel/hand rub available in all delivery, recovery, postnatal and neonatal care rooms 0% of health facilities have adequate sink handwashing facilities5 in all delivery, recovery, postnatal and neonatal care rooms 100% of health facilities have clean and dry newborn resuscitation areas PRETERM BABIES, 20174 NEWBORN CARE PRACTICES * Women of 24–34 weeks of gestational age Functional bag and mask within 2 m of delivery beds 0 20 40 60 80 100 Percentage of postpartum mothers Data from interviews and chart reviews of postpartum mothers: – 10 at national hospitals (n = 1) and – 33 at subnational health facilities (n = 9) 70 76 82 Encouraged to eat and drink during labour 30 15Syphilis testing recorded 91With companion during childbirth 27 0Episiotomy 50 no dataOxytocin injected within 1 min of birth10 42 100Partographs completed correctly national hospital subnational hospital 94 Not in supine position during active labour ANTENATAL CARE AND DELIVERY PRACTICES, 20174 80 60 Percentage COVERAGE OF KEY INTERVENTIONS, 20157 0 20 40 60 80 100 86Skilled attendance at birth 85Facility delivery rate 6Births delivered by caesarean section 79Breastfeeding initiated within ≤ 1 hour of birth 69Women who received PNC* in ≤ 2 days of birth 16Newborns who received PNC* in ≤ 2 days of birth introduced in 48% of health facilities (145/302) 58% of staff coached (408/710) 13% have EENC teams8 0% have established a quality improvement approach8,9 * postnatal care EENC 58% 13% 0% Of the facilities that have introduced EENC: EENC IMPLEMENTATION, 20173 Skin-to-skin contact no data Exclusive breastfeeding from 0 to 1 month 87 0 20 40 60 80 100 Percentage of term babies Data from interviews with postpartum mothers: – 10 at national hospital (n = 1), and – 33 at subnational health facilities (n = 9) 80 64 Prolonged (≥ 90 min) skin-to-skin contact 70 70Immediate skin-to-skin contact 80 70 Sustained skin-to-skin contact until first breastfeed 90 55 Received early and exclusive breastfeeding 50 67Bathed in > 24 hours 67 0Skin-to-skin contact applied in C-section deliveries national hospital subnational hospital TERM BABIES, 20174 I 14 no data Early EssEntial nEwborn CarE (EEnC) 2017 0 10 20 30 40 50 60 W PR /2 01 7/ DN H/ 01 3 – © W or ld H ea lth O rg an iza tio n 20 17 – S om e rig ht s re se rv ed . T hi s w or k is av ai la bl e un de r t he C C BY -N C- SA 3 .0 IG O li ce ns e. 69 early essential neWBorn care VIET NAM (1) NAM NEONATAL MORTALITY RATE 1 1990 2014 2020 23 12 7 Neonatal deaths (per 1000 live births) Percentage Target in national EENC 5-year action plan CAUSES OF NEONATAL DEATH, 20162 Preterm 40% Sepsis/ Pneumonia 16% Asphyxia 14% Congenital anomalies 23% Other 7% COVERAGE OF KEY INTERVENTIONS, 20167 0 20 40 60 80 100 98Skilled attendance at birth 97Facility delivery rate Detailed 12-month EENC implementation plan developed and funded EENC technical working group formed 28Births delivered by caesarean section 73Breastfeeding initiated within ≤ 1 hour of birth 90Women who received PNC* in ≤ 2 days of birth 89Newborns who received PNC* in ≤ 2 days of birth introduced in 88% of hospitals (687/784) 53% of staff coached (8613/16 354) 63% have EENC teams4 13% have established a quality improvement approach4,8 * postnatal care 1. Level and Trends in Child Mortality: Report 2017. UNICEF, 2017. Multiple Indicator Cluster Survey Viet Nam, 2014. 2. WHO Global Health Observatory, 2018. 3. Ministry of Health, 2007. 4. Based on data from assessments of 48 randomly selected hospitals that have introduced EENC, 2017. 5. Adequate handwashing facilities defined as having at least one sink in the room, and all sinks in the room having running water, soap, and single-use towels/re-usable sterile towels/hand dryers available. 6. Adequate hand hygiene comprises washing hands twice before gloving and using sterile gloves to cut the umbilical cord. 7. Viet Nam Reproductive Health Annual Report, 2016. Multiple Indicator Cluster Surveys Viet Nam, 2014 (births delivered by caesarean section, and indicators on postnatal care) and 2011 (exclusive breastfeeding 0–1 month). 8. Quality improvement approach consists of: (1) regular and documented meetings of the EENC team, (2) at least two EENC assessments per year, and (3) developing and updating an EENC hospital action plan at least quarterly. 9. Data from observations of 21 deliveries at 3 national hospitals and 55 deliveries at 24 subnational hospitals. EENC 61% PARTIAL 63% 13% EENC included in pre-service curricula (medical, midwifery and nursing) EENC 5-year action plan developed, costed and adopted Clinical intra-partum and newborn care protocol adapted, reviewed and endorsed YES NO STOCK-OUTS OF KEY MEDICINES AND COMMODITIES FOR EENC IN THE PAST 12 MONTHS, 20174 Antibiotics for sepsis Vitamin K Corticosteroids Magnesium sulfate Oxytocin Functional bag and mask within 2 m of delivery beds 0 1 2–4 > 4 Number of stock-outs across 48 hospitals (3 national hospitals and 45 subnational hospitals) 0 20 40 60 80 100 0 0 20 20 40 40 60 60 80 80 100 100 Percentage of postpartum mothers Percentage of preterm babies Percentage of term babies Data from interviews and chart reviews of postpartum mothers: – 38 at national hospitals (n = 3) and – 389 at subnational hospitals (n = 45) Of the facilities that have introduced EENC4: Data from interviews and chart reviews of postpartum mothers: – 29 at national hospitals (n = 3), and – 45 at subnational hospitals (n = 15) Data from observations in 48 hospitals (3 national hospitals and 45 subnational hospitals) Data from interviews with postpartum mothers: – 38 at national hospitals (n = 3), and – 389 at subnational hospitals (n = 45) 71 69 Encouraged to eat and drink during labour 76 25 Prolonged (≥ 90 min) skin-to-skin contact 85 3Syphilis testing recorded 38 45 Pregnant women* at risk of preterm labour receiving corticosteroids 82 96Immediate skin-to-skin contact 83 44Immediate skin-to-skin contact 100 53 Sustained skin-to-skin contact until first breastfeed 1 4With companion during childbirth 4 62Prolonged (≥ 90 min) skin-to-skin contact 68 61 Received early and exclusive breastfeeding 70 71Episiotomy 98 100Oxytocin injected within 1 min of birth9 77 100Bathed in > 24 hours 14 67Skin-to-skin contact applied in C-section deliveries 68 68Partographs completed correctly Sustained skin-to-skin contact until first breastfeed national hospital national hospital national hospital subnational hospital subnational hospital subnational hospital 12 Not in supine position during active labour 0 Pregnant women < 32 weeks of gestational age receiving MgSO4 Received Kangaroo Mother Care 35 Received early and exclusive breastfeeding ANTENATAL CARE AND DELIVERY PRACTICES, 20174 ENVIRONMENTAL HYGIENE, 20174 KEY POINTS • 53% of all under-5 deaths in Viet Nam now occur in the newborn period. • Around 60% of hospital staff providing chidlbirth and newborn care have been coached in EENC at each level. • Almost all women are injected with oxytocin within 1 minute of child- birth. However, very few pregnant women have a companion during childbirth and encouraged to assume a non-supine positive during active labour. • Preterm newborns are less likely to receive EENC, which places them at higher risk of poor health outcomes. • Stock-outs of key medicines and commodities are more frequently reported in district hospitals than in provincial and national hospitals. • No hospital has adequate sink handwashing facilities in all maternal and neonatal care rooms. Adequate hand hygiene is practised in 4 out of 5 deliveries. Adequate hand hygiene6 practised in 79% of deliveries 19% of hospitals have alcohol gel/hand rub available in all delivery, recovery, postnatal and neonatal care rooms 0% of hospitals have adequate sink handwashing facilities5 in all delivery, recovery, postnatal and neonatal care rooms 90% of hospitals have clean and dry newborn resuscitation areas PRETERM BABIES, 20174 TERM BABIES, 20174 NEWBORN CARE PRACTICES * Women of 24–34 weeks of gestational age EENC IMPLEMENTATION, 20174 Hepatitis B vaccine no data 10 25 62 62 11 9 31 Skin-to-skin contact Exclusive breastfeeding from 0 to 1 month 27 PROGRAMME READINESS FOR EENC SCALE-UP 20173 Early EssEntial nEwborn CarE (EEnC) 2017 59 0 10 20 30 40 50 60 W PR /2 01 7/ DN H/ 01 4 – © W or ld H ea lth O rg an iza tio n 20 17 – S om e rig ht s re se rv ed . T hi s w or k is av ai la bl e un de r t he C C BY -N C- SA 3 .0 IG O li ce ns e. 70 second BIENNIAL PROGRESS REPORT (2016–2017) VIET NAM (2) early essential neWBorn care VIET NAM NEONATAL MORTALITY RATE 1 1990 2014 2020 23 12 7 Neonatal deaths (per 1000 live births) Percentage Target in national EENC 5-year action plan CAUSES OF NEONATAL DEATH, 20162 Preterm 40% Sepsis/ Pneumonia 16% Asphyxia 14% Congenital anomalies 23% Other 7% COVERAGE OF KEY INTERVENTIONS, 20167 0 20 40 60 80 100 98Skilled attendance at birth 97Facility delivery rate Detailed 12-month EENC implementation plan developed and funded EENC technical working group formed 28Births delivered by caesarean section 73Breastfeeding initiated within ≤ 1 hour of birth 90Women who received PNC* in ≤ 2 days of birth 89Newborns who received PNC* in ≤ 2 days of birth introduced in 88% of hospitals (687/784) 53% of staff coached (8613/16 354) 63% have EENC teams4 13% have established a quality improvement approach4,8 * postnatal care 1. Level and Trends in Child Mortality: Report 2017. UNICEF, 2017. Multiple Indicator Cluster Survey Viet Nam, 2014. 2. WHO Global Health Observatory, 2018. 3. Ministry of Health, 2007. 4. Based on data from assessments of 48 randomly selected hospitals that have introduced EENC, 2017. 5. Adequate handwashing facilities defined as having at least one sink in the room, and all sinks in the room having running water, soap, and single-use towels/re-usable sterile towels/hand dryers available. 6. Adequate hand hygiene comprises washing hands twice before gloving and using sterile gloves to cut the umbilical cord. 7. Viet Nam Reproductive Health Annual Report, 2016. Multiple Indicator Cluster Surveys Viet Nam, 2014 (births delivered by caesarean section, and indicators on postnatal care) and 2011 (exclusive breastfeeding 0–1 month). 8. Quality improvement approach consists of: (1) regular and documented meetings of the EENC team, (2) at least two EENC assessments per year, and (3) developing and updating an EENC hospital action plan at least quarterly. 9. Data from observations of 21 deliveries at 3 national hospitals and 55 deliveries at 24 subnational hospitals. EENC 61% PARTIAL 63% 13% EENC included in pre-service curricula (medical, midwifery and nursing) EENC 5-year action plan developed, costed and adopted Clinical intra-partum and newborn care protocol adapted, reviewed and endorsed YES NO STOCK-OUTS OF KEY MEDICINES AND COMMODITIES FOR EENC IN THE PAST 12 MONTHS, 20174 Antibiotics for sepsis Vitamin K Corticosteroids Magnesium sulfate Oxytocin Functional bag and mask within 2 m of delivery beds 0 1 2–4 > 4 Number of stock-outs across 48 hospitals (3 national hospitals and 45 subnational hospitals) 0 20 40 60 80 100 0 0 20 20 40 40 60 60 80 80 100 100 Percentage of postpartum mothers Percentage of preterm babies Percentage of term babies Data from interviews and chart reviews of postpartum mothers: – 38 at national hospitals (n = 3) and – 389 at subnational hospitals (n = 45) Of the facilities that have introduced EENC4: Data from interviews and chart reviews of postpartum mothers: – 29 at national hospitals (n = 3), and – 45 at subnational hospitals (n = 15) Data from observations in 48 hospitals (3 national hospitals and 45 subnational hospitals) Data from interviews with postpartum mothers: – 38 at national hospitals (n = 3), and – 389 at subnational hospitals (n = 45) 71 69 Encouraged to eat and drink during labour 76 25 Prolonged (≥ 90 min) skin-to-skin contact 85 3Syphilis testing recorded 38 45 Pregnant women* at risk of preterm labour receiving corticosteroids 82 96Immediate skin-to-skin contact 83 44Immediate skin-to-skin contact 100 53 Sustained skin-to-skin contact until first breastfeed 1 4With companion during childbirth 4 62Prolonged (≥ 90 min) skin-to-skin contact 68 61 Received early and exclusive breastfeeding 70 71Episiotomy 98 100Oxytocin injected within 1 min of birth9 77 100Bathed in > 24 hours 14 67Skin-to-skin contact applied in C-section deliveries 68 68Partographs completed correctly Sustained skin-to-skin contact until first breastfeed national hospital national hospital national hospital subnational hospital subnational hospital subnational hospital 12 Not in supine position during active labour 0 Pregnant women < 32 weeks of gestational age receiving MgSO4 Received Kangaroo Mother Care 35 Received early and exclusive breastfeeding ANTENATAL CARE AND DELIVERY PRACTICES, 20174 ENVIRONMENTAL HYGIENE, 20174 KEY POINTS • 53% of all under-5 deaths in Viet Nam now occur in the newborn period. • Around 60% of hospital staff providing chidlbirth and newborn care have been coached in EENC at each level. • Almost all women are injected with oxytocin within 1 minute of child- birth. However, very few pregnant women have a companion during childbirth and encouraged to assume a non-supine positive during active labour. • Preterm newborns are less likely to receive EENC, which places them at higher risk of poor health outcomes. • Stock-outs of key medicines and commodities are more frequently reported in district hospitals than in provincial and national hospitals. • No hospital has adequate sink handwashing facilities in all maternal and neonatal care rooms. Adequate hand hygiene is practised in 4 out of 5 deliveries. Adequate hand hygiene6 practised in 79% of deliveries 19% of hospitals have alcohol gel/hand rub available in all delivery, recovery, postnatal and neonatal care rooms 0% of hospitals have adequate sink handwashing facilities5 in all delivery, recovery, postnatal and neonatal care rooms 90% of hospitals have clean and dry newborn resuscitation areas PRETERM BABIES, 20174 TERM BABIES, 20174 NEWBORN CARE PRACTICES * Women of 24–34 weeks of gestational age EENC IMPLEMENTATION, 20174 Hepatitis B vaccine no data 10 25 62 62 11 9 31 Skin-to-skin contact Exclusive breastfeeding from 0 to 1 month 27 PROGRAMME READINESS FOR EENC SCALE-UP 20173 Early EssEntial nEwborn CarE (EEnC) 2017 59 0 10 20 30 40 50 60 W PR /2 01 7/ DN H/ 01 4 – © W or ld H ea lth O rg an iza tio n 20 17 – S om e rig ht s re se rv ed . T hi s w or k is av ai la bl e un de r t he C C BY -N C- SA 3 .0 IG O li ce ns e. 71 72 chair’s statement of the high-level forum on accelerating progress in early essential newborn care Chair’s statement of the High-level Forum on Accelerating Progress in Early Essential Newborn Care, 17 August 2017, Da Nang, Socialist Republic of Viet Nam 1. The Western Pacifi c Region High-level Forum on Accelerating Early Essential Newborn Care was held on 16–17 August 2017 in Da Nang, Viet Nam. The Forum was chaired by H.E. Professor Nguyen Viet Tien, Vice Minister of Health Viet Nam, supported by Honourable Herminigildo V. Valle Undersecretary of Health of the Philippines, as a Vice-Chair. The meeting was attended by Vice-Ministers of Health, Undersecretaries, Assistant Secretaries and representatives from Cambodia, China, the Lao People’s Democratic Republic, Mongolia, Papua New Guinea, the Philippines, Solomon Islands and Viet Nam. 2. We, the Vice-Ministers, Undersecretaries, Assistant Secretaries and representatives (of the eight countries), had a positive and productive discussion through exchanging experiences with ac- celerating Early Essential Newborn Care (EENC) since the last biennial meeting in 2015. 3. We reaffi rm that ensuring an enabling sociopolitical economic environment is required for a healthy start for every newborn and a safe motherhood, and to make progress towards achiev- ing universal health coverage (UHC) and the Sustainable Development Goals (SDGs) principle of leaving no one behind. 4. We recognize the health, economic and social consequences of illness and death of pregnant and post-partum women in their prime of life and their babies. Their mortality and morbidity constitute a large burden, particularly in low-income and low-middle-income countries, and require urgent unifi ed action at national, regional and global levels. We underscore that promi- nent investments in EENC will have a strong impact on the health and well-being of women, newborns and society. 5. We reiterate the need for accelerated action emphasized in the United Nations Secretary-General’s Global Strategy for Women’s, Children’s and Adolescents’ Health (2016–2030) and by the Every Newborn Action Plan (2014), the World Health Assembly Resolution 64.R13 Working towards the reduction of perinatal and neonatal mortality (2011) and the Action Plan for Healthy Newborn Infants in the Western Pacifi c Region (2014–2020). 6. We are proud of the signifi cant progress made by the countries in our Region, with over 30 000 health workers from over 2500 health facilities now participating, and the vast improvements in the quality of care provided by them. However, we recognize the need to expand coverage of EENC to reach approximately fi ve times more mothers and newborns. annex 6 73 7. We note with satisfaction the implementation of the recommended actions of the First Biennial Meeting on Accelerating Early Essential Newborn Care held in Tokyo in 2015. 8. We highlight the challenges of scaling up EENC posed by outdated health provider practices; weak accreditation standards and quality improvement mechanisms; weak and/or unenforced regulation of conflicts of interest; lack of quality information generated from national and re- gional health information systems to guide policy development and clinical decision-making; and, insufficient resources. 9. We also note with grave concern that marketing of breastmilk substitutes remains rampant and is a challenge to increasing exclusive breastfeeding prevalence. We reaffirm our strong com- mitment to the International Code of Marketing of Breastmilk Substitutes, the Mother–Baby Friendly Hospital Initiative and the related World Health Assembly Resolutions. 10. We emphasize the importance of identifying and eliminating conflicts of interest at all levels of the health system that result in suboptimal feeding; unnecessary admissions; medical procedures; and harmful practices. 11. We further note that harmful practices such as unnecessary admissions into neonatal care units and unnecessary medical procedures expose newborns and mothers to unnecessary risk of health facility acquired infections, long-term disability and death. 12. We pledge to continue our efforts to provide quality care to all mothers and newborns by; in- creasing awareness and understanding of standards of appropriate care; increasing multi-sectoral collaboration to identify underlying problems and implement sustainable actions and system changes to benefit women and newborns, in accordance with national EENC action plans and policies; enforcing laws and regulations to prevent conflicts of interest and harmful and un- necessary medical practices; and, actively and effectively supporting and monitoring progress of national EENC action plans. 13. We reiterate our commitment to build a resilient health system, in line with national strategies for the attainment of SDGs, especially universal health coverage; and, to strengthen national capacities to scale up EENC by intensifying ongoing multisectoral efforts to support national EENC action plans. 14. We reaffirm our commitment to work together to promote international and regional collabora- tion and partnerships to strengthen country and regional surveillance, response, and research and development capacity to make EENC available at every delivery toward UHC in the Region. 15. We request the WHO and UNICEF, through the Secretariat, to support an EENC network to share lessons learned and enable other exchanges such as study tours. 16. We acknowledge continued support from the WHO, UNICEF and other development partners and request ongoing support to countries in the Region to accelerate adoption and scale-up of EENC interventions.

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