Maintaining health-system functionality in response to the surge of COVID-19 cases due to the Omicron variant, Japan

Problem

The Omicron variant of severe acute respiratory syndrome coronavirus 2 caused the largest surge of coronavirus disease (COVID-19) cases in Japan starting in the summer of 2022. We describe the mechanisms introduced to provide appropriate health care to all Omicron cases, provide appropriate health care to all non-COVID-19 patients, and protect health-care workers (HCWs) while providing necessary health services. Optimization of care for elderly patients was particularly important.

Context

Japan is home to 125 million people, of whom 28.6% are 65 years or older. Between January and June 2022, the country experienced 4.3 times more COVID-19 cases than in the previous 2 years (7.3 million vs 1.7 million).

Action

To adjust care pathways, inpatient treatment capacity was increased, a home-based care system was established, and an on-site treatment scheme at long-term care facilities was started. Among essential health services, disruption of emergency care became most noticeable. Administrative and financial support was provided to hospitals with emergency departments to maintain emergency medical services. To protect HCWs while maintaining hospital services, flexible exemptions were introduced to enable those who became close contacts to return to work, and broadly targeted contact tracing and testing in case of nosocomial outbreaks were all helpful.

Outcome

As a result of the adjustments made to inpatient capacity and patient flow, bed occupancy for COVID-19 patients decreased, mostly because many patients were cared for at home or in temporary-care facilities.

Discussion

From this study, we extracted two essential lessons to aid in current and future health emergencies: how to balance the provision of acute medical care for elderly patients and maintain their well-being; and how to maintain essential health services.

Factors associated with high exclusive breastfeeding rates among preterm infants under 34 weeks of gestation in Da Nang, Vietnam: A retrospective cohort study

Background

Preterm infants have higher mortality than full-term infants. While breastfeeding dramatically reduces preterm death, it is limited by biological and practice barriers, particularly for babies born before 34 weeks gestational age. Da Nang Hospital for Women and Children developed a quality improvement approach to improve breastfeeding of preterm infants by strengthening feeding support, non-separation, and kangaroo mother care (KMC).

Methods

To determine breastfeeding outcomes following discharge and explore factors associated with improved feeding, mothers of infants under 34 weeks gestational age born October 2021 to March 2022 and discharged alive were interviewed at six months and their medical records were reviewed.

Results

Out of 104 preterm infants included, all were exclusively breastfed at discharge and one month, 86.5% at three months, and 63.5% at six months; 47.1% received immediate skin-to-skin contact, 31.7% immediate and continuous KMC, and the remaining 68.3% continuous KMC beginning at a median of three days. Exclusive breastfeeding at six months was associated with the mother antenatally seeking breastfeeding information (odds ratio (OR) = 14.5; 95% confidence interval (CI) = 1.2-173.6), avoiding bottle-feeding at home (OR = 7.7; 95% CI = 1.7-33.7) and reduced with each day delay between birth and full breastfeeding (OR = 0.8; 95% CI = 0.6-0.9).

Conclusions

Hospital environments that limit mother-baby separations and feeding delays, including rooming-in of mothers and infants, KMC, and breastfeeding support from birth, enabled 100% of preterm infants born before 34 weeks gestational age to breastfeed exclusively with continued rates higher than previously reported. Addressing antenatal and post-natal factors limiting practice can further improve longer-term breastfeeding outcomes. The approach can be adapted to achieve high exclusive breastfeeding rates, regardless of gestational age.

A research agenda to improve incidence and outcomes of assisted vaginal birth

Access to emergency obstetric care, including assisted vaginal birth and caesarean birth, is crucial for improving maternal and childbirth outcomes. However, although the proportion of births by caesarean section has increased during the last few decades, the use of assisted vaginal birth has declined. This is particularly the case in low- and middle-income countries, despite an assisted vaginal birth often being less risky than caesarean birth. We therefore conducted a three-step process to identify a research agenda necessary to increase the use of, or reintroduce, assisted vaginal birth: after conducting an evidence synthesis, which informed a consultation with technical experts who proposed an initial research agenda, we sought and incorporated the views of women's representatives of this agenda. This process has allowed us to identify a comprehensive research agenda, with topics categorized as: (i) the need to understand women's perceptions of assisted vaginal birth, and provide appropriate and reliable information; (ii) the importance of training health-care providers in clinical skills but also in respectful care, effective communication, shared decision-making and informed consent; and (iii) the barriers to and facilitators of implementation and sustainability. From women's feedback, we learned of the urgent need to recognize labour, childbirth and postpartum experiences as inherently physiological and dignified human processes, in which interventions should only be implemented if necessary. The promotion and/or reintroduction of assisted vaginal birth in low-resource settings requires governments, policy-makers and hospital administrators to support skilled health-care providers who can, in turn, respectfully support women in labour and childbirth.

Experiences in COVID-19 clinical management and health-care pathways in the Western Pacific

The coronavirus disease (COVID-19) pandemic has transformed clinical practice and health systems. This paper provides an overview of COVID-19 clinical management and health-care pathway challenges that the World Health Organization and its Member States in the Western Pacific Region have faced. The experiences and lessons identified can help countries to better prepare for future pandemics.

A case for updating the WHO Safe Childbirth Checklist to improve newborn care: Experience from seven Asia and Pacific countries

The WHO Safe Childbirth Checklist (the SCC) is a clinical tool developed to help health workers follow evidence-based maternal and perinatal care practices at childbirth. Newborn delivery care practices at facilities in seven countries in East Asia and the Pacific were compared to practices checked by the SCC. The analysis found that the SCC does not incorporate several key evidence-based practices around birth demonstrated to prevent newborn morbidity or mortality, or harmful practices associated with increased risks. A revision of the standard SCC is needed to maximise its potential to improve newborn outcomes. This can be initiated under the coordinating umbrella of WHO, but must ensure that the realities of labour and childbirth practices in low- and middle-income countries are considered and addressed.

Status of water, sanitation and hygiene services for childbirth and newborn care in eight countries in East Asia and the Pacific

Background

Water, sanitation and hygiene (WASH) services are critical to providing quality maternal and neonatal care in health facilities. This study aimed to investigate availability of WASH policies, standards, and services for childbirth and newborn care in hospitals in East Asia and the Pacific.

Methods

Descriptive analysis of survey data and observations of water, sanitation and hygiene services in maternity and neonatal care rooms and of deliveries in 147 hospitals in Cambodia, Lao People’s Democratic Republic, Mongolia, Papua New Guinea, Philippines, Solomon Islands, and Viet Nam. The main outcome measures were availability of national policies and standards; availability of water, sanitation, and hygiene services in maternity rooms and neonatal care units; and practice of hygiene at childbirth.

Results

Three of seven countries had national WASH policies and three had standards for health facilities. Seventy-seven percent of hospitals had a sink with water and soap or alcohol hand rub in delivery rooms, 78% in neonatal care rooms and 42% in postnatal care rooms. Only 44% of hospitals had clean sinks with water, soap and hand drying methods in the delivery room, 40% in neonatal care units and 10% in postnatal care rooms. Flush toilets were available in or next to delivery rooms in 60% and neonatal care units in 50% of 10 hospitals with data. Countries with WASH standards had a higher proportion of hospitals with water and hand hygiene services. Appropriate hygiene was practiced by health workers in 65% of 371 deliveries observed, and more likely in delivery rooms with a sink, water and soap.

Conclusions

Coverage of WASH services for maternal and newborn care must be improved to reduce risks of maternal and newborn morbidity and mortality.

Reasons for discontinuation of contraception among women with a current unintended pregnancy in 36 low and middle-income countries

OBJECTIVES

To explore the reasons for discontinuation of the last contraceptive method used in women with a current unintended pregnancy.

STUDY DESIGN

We conducted a retrospective analysis using contraceptive calendar data from Demographic and Health Surveys from 36 low- and middle-income countries from 2005 through 2014. The prevalence of contraception utilization and the contribution of each reason for contraceptive discontinuation was calculated, at country level as well as for the pooled dataset, for 10,901 women aged 15-49 before the current unintended pregnancies.

RESULTS

Unintended pregnancies ranged from 5.5% of all pregnancies in the Kyrgyz Republic to 60.0% in Colombia and Peru. In Central Asian and in six African countries, over 80% of women with a current unintended pregnancy had not used any contraceptives in the previous five years. Use of long-acting modern methods remained consistently low across all countries. Among women who last used a traditional method, 83.8% discontinued due to failure. Among women who last used a long-acting modern method, 40.2% discontinued because of side effects.

CONCLUSIONS

Our findings confirm that more than 65.0% of women with an unintended pregnancy in 36 low and middle-income countries were either non-users or using traditional methods. An additional 31.2% were using short-acting modern methods. Long-acting methods would have prevented the overwhelming majority of unintended pregnancies.

IMPLICATIONS

This paper shows the need for the health system to support use of suitable methods, reduce switching failure and identify early when women are having concerns about the method they are using.

Opportunities lost: Barriers to increasing the use of effective contraception in the Philippines

Background

In the Philippines, one in four pregnancies are unintended and 610 000 unsafe abortions are performed each year. This study explored the association between missed opportunities to provide family planning counseling, quality of counseling and its impact on utilization of effective contraception in the Philippines.

Methods

One-hundred-one nationally representative health facilities were randomly selected from five levels of the health system. Sexually-active women 18–49 years old, wanting to delay or limit childbearing, attending primary care clinics between April 24 and August 8, 2017 were included. Data on contraceptive use, counseling and availability were collected using interviews and facility assessments. Effective contraceptive methods were defined as those with rates of unintended pregnancy of less than 10 per 100 women in first year of typical use.

Findings

849 women were recruited of whom 51.1% currently used effective contraceptive methods, 20.6% were former effective method users and 28.3% had never used an effective method. Of 1664 cumulative clinic visits reported by women in the previous year, 72.6% had a missed opportunity to receive family planning counseling at any visit regardless of level of facility, with 83.7% having a missed counseling opportunity on the day of the interview. Most women (55.9%) reported health concerns about modern contraception, with 2.9% receiving counseling addressing their concerns. Only 0.6% of former users and 2.1% never-users said they would consider starting a modern contraceptive in the future. Short and long acting reversible contraceptive methods were available in 93% and 68% of facilities respectively.

Conclusions

Missed opportunities to provide family planning counseling are widespread in the Philippines. Delivery of effective contraceptive methods requires that wider legal, policy, social, cultural, and structural barriers are addressed, coupled with systems approaches for improving availability and quality of counseling at all primary health care contacts.

Improving immediate newborn care practices in Philippine hospitals: impact of a national quality of care initiative 2008-2015

Objective

To determine whether intrapartum and newborn care practices improved in 11 large hospitals between 2008 and 2015.

Design

Secondary data analysis of observational assessments conducted in 11 hospitals in 2008 and 2015.

Setting

Eleven large government hospitals from five regions in the Philippines.

Participants

One hundred and seven randomly sampled postpartum mother-baby pairs in 2008 and 106 randomly sampled postpartum mothers prior to discharge from hospitals after delivery.

Interventions

A national initiative to improve quality of newborn care starting in 2009 through development of a standard package of intrapartum and newborn care services, practice-based training, formation of multidisciplinary hospital working groups, and regular assessments and meetings in hospitals to identify actions to improve practices, policies and environments. Quality improvement was supported by policy development, health financing packages, health facility standards, capacity building and health communication.

Main outcome measures

Sixteen intrapartum and newborn care practices.

Results

Between 2008 and 2015, initiation of drying within 5 s of birth, delayed cord clamping, dry cord care, uninterrupted skin-to-skin contact, timing and duration of the initial breastfeed, and bathing deferred until 6 h after birth all vastly improved (P<0.001). The proportion of newborns receiving hygienic cord handling and the hepatitis B birth dose decreased by 11-12%. Except for reduced induction of labor, inappropriate maternal care practices persisted.

Conclusions

Newborn care practices have vastly improved through an approach focused on improving hospital policies, environments and health worker practices. Maternal care practices remain outdated largely due to the ineffective didactic training approaches adopted for maternal care.

Early Essential Newborn Care Is Associated With Reduced Adverse Neonatal Outcomes in a Tertiary Hospital in Da Nang, Viet Nam: A Pre- Post- Intervention Study

BACKGROUND

To accelerate reductions in neonatal mortality, Viet Nam rolled out early essential newborn care (EENC) using clinical coaching, quality improvement assessments in hospitals, and updated protocols. Da Nang Hospital for Women and Children, a tertiary referral hospital in central Viet Nam, compared outcomes pre- and post-EENC introduction.

METHODS

Records of live births and NICU admissions were reviewed pre- (November 2013-October 2014) and post- (November 2014-October 2015) EENC implementation. Delivery room practices, NICU admissions and adverse outcomes on NICU admission were compared using descriptive statistics.

FINDINGS

A total of 13,201 live births were delivered pre- and 14,180 live births post-EENC introduction. Post-EENC, delivery practice scores, rates of early and prolonged skin-to-skin contact and early breastfeeding rose significantly. There was a significant reduction in risk of NICU admissions (relative risk [RR] 0.68; 95% confidence interval [CI] 0.64-0.71; p < 0.0001), hypothermia on NICU admission (RR 0.72; 95% CI 0.65-0.81, p < 0.0001) and sepsis (RR 0.28; 95% CI 0.23-0.35, p < 0.0001). Exclusive breastfeeding rates in NICU increased from 49% to 88% (p < 0.0001) and of kangaroo mother care (KMC) from 52% to 67% (p < 0.0001). Reduced formula use resulted in decreased monthly costs.

INTERPRETATION

EENC introduction, including staff coaching, quality improvement assessments and changes in hospital protocols and environments, were associated with improved clinical practices, reduced NICU admissions, admissions with hypothermia and sepsis and increased rates of exclusive breastfeeding and KMC in the NICU.

FUNDING

Data collection was funded by the World Health Organization Western Pacific Regional Office and Newborns Vietnam.

OUTSTANDING QUESTIONS

•What is the impact of the package of early essential newborn care interventions on newborn mortality?•What are the total direct and indirect cost savings of early essential newborn care implementation?•What is the cost effectiveness of kangaroo mother care for preterm and low birth weight babies?•What strategies can help reduce unnecessary cesarean sections in hospitals?

Signs of eclampsia during singleton deliveries and early neonatal mortality in low- and middle-income countries from three WHO regions

OBJECTIVE

To determine the prevalence of eclampsia symptoms and to explore associations between eclampsia and early neonatal mortality.

METHODS

The present secondary analysis included Demographic and Health Surveys data from 2005 to 2012; details of signs related to severe obstetric adverse events of singleton deliveries during interviewees' most recent delivery in the preceding 5 years were included. Data and delivery history were merged for pooled analyses. Convulsions-used as an indicator for having experienced eclampsia-and early neonatal mortality rates were compared, and a generalized random effect model, adjusted for heterogeneity between and within countries, was used to investigate the impact of presumed eclampsia on early neonatal mortality.

RESULTS

The merged dataset included data from six surveys and 55 384 live deliveries that occurred in Colombia, Bangladesh, Indonesia, Mali, Niger, and Peru. Indications of eclampsia were recorded for 1.2% (95% confidence interval [CI] 1.0-1.3), 1.7% (95% CI 1.5-2.1), and 1.7% (95% CI 1.5-2.1) of deliveries reported from the American, South East Asian, and African regions, respectively. Pooled analyses demonstrated that eclampsia was associated with increased risk of early neonatal mortality (adjusted risk ratio 2.1 95% CI 1.4-3.2).

CONCLUSION

Increased risk of early neonatal mortality indicates a need for strategies targeting the early detection of eclampsia and early interventions.

Effect of Puerperal Infections on Early Neonatal Mortality: A Secondary Analysis of Six Demographic and Health Surveys

Background

Around 1.5 million annual neonatal deaths occur in the first week of life, and infections represent one of the major causes in developing countries. Neonatal sepsis is often strictly connected to infection of the maternal genital tract during labour.

Methods

The association between signs suggestive of puerperal infection and early neonatal mortality (<7 days of life) was performed using Demographic and Health Surveys (DHS) data of six countries, conducted between 2010 and 2013. The population attributable fraction (PAF) was generated using the estimates on early neonatal mortality of a 1990–2013 systematic analysis for the Global Burden of Disease Study.

Results

Signs of puerperal infection ranged from 0.7% in the Philippines to 16.4% in Honduras. Infection was associated with a 2.1 adjusted Risk Ratio (95% CI: 1.4–3.2) of early neonatal mortality. Around five percent of all deaths in the first week of life were attributable to signs suggestive of puerperal infections and varied from 13.9% (95% CI: 1.0–26.6) in Honduras to 3.6% (95% CI: 1.0–8.5) in Indonesia.

Conclusions

Targeted interventions should be addressed to contain the burden of puerperal infections on early neonatal mortality. Consideration of the PAF will help in the discussion of the benefits of antenatal and perinatal measures.

Does place and attendance at birth improve early neonatal mortality? Secondary analysis of nine Demographic and Health Surveys

OBJECTIVES

To determine the relation between place and skilled birth attendance at birth and early neonatal mortality.

DESIGN

Retrospective analysis using data from Demographic and Health Surveys on obstetric complications.

SETTING

Nine low and middle income countries between 2006 and 2013.

POPULATION

71 758 women aged 15-49 years.

METHODS

A secondary analysis was carried out to investigate the occurrence and effect of obstetric complications on early neonatal mortality and association with place and attendance at birth. Obstetric complications studied were prolonged labour, puerperal infection and eclampsia.

MAIN OUTCOME MEASURES

Association between early neonatal mortality and place and attendance at birth, unadjusted and adjusted for presence of severe obstetric complications.

RESULTS

Thirty-five percent of all births were at home: 70% of these were without skilled attendamts. Obstetric complications were reported in 17 079 women: 82% of these women gave birth in health facilities. Overall, no association was observed between place of birth or attendance at birth and early neonatal mortality. When adjusted for obstetric complications, the odds of early neonatal deaths for births at home without a skilled attendant were 1.3 (95% CI 1.1-1.5) compared with 1.2 (95% CI 1.0-1.5) with a skilled attendant and births in health facilities.

CONCLUSIONS

When adjusted for obstetric complications, births in health facilities were associated with reduced early neonatal mortality. However, reporting and referral bias account for at least part of the association.

TWEETABLE ABSTRACT

Births in health facilities are linked with fewer early newborn deaths when adjusted for obstetric complications.

Basic newborn care and neonatal resuscitation: a multi-country analysis of health system bottlenecks and potential solutions

BACKGROUND

An estimated two-thirds of the world's 2.7 million newborn deaths could be prevented with quality care at birth and during the postnatal period. Basic Newborn Care (BNC) is part of the solution and includes hygienic birth and newborn care practices including cord care, thermal care, and early and exclusive breastfeeding. Timely provision of resuscitation if needed is also critical to newborn survival. This paper describes health system barriers to BNC and neonatal resuscitation and proposes solutions to scale up evidence-based strategies.

METHODS

The maternal and newborn bottleneck analysis tool was applied by 12 countries in Africa and Asia as part of the Every Newborn Action Plan process. Country workshops engaged technical experts to complete the survey tool, which is designed to synthesise and grade health system "bottlenecks" that hinder the scale up of maternal-newborn intervention packages. We used quantitative and qualitative methods to analyse the bottleneck data, combined with literature review, to present priority bottlenecks and actions relevant to different health system building blocks for BNC and neonatal resuscitation.

RESULTS

Eleven of the 12 countries provided grading data. Overall, bottlenecks were graded more severely for resuscitation. The most severely graded bottlenecks for BNC were health workforce (8 of 11 countries), health financing (9 out of 11) and service delivery (7 out of 9); and for neonatal resuscitation, workforce (9 out of 10), essential commodities (9 out of 10) and service delivery (8 out of 10). Country teams from Africa graded bottlenecks overall more severely. Improving workforce performance, availability of essential commodities, and well-integrated health service delivery were the key solutions proposed.

CONCLUSIONS

BNC was perceived to have the least health system challenges among the seven maternal and newborn intervention packages assessed. Although neonatal resuscitation bottlenecks were graded more severe than for BNC, similarities particularly in the workforce and service delivery building blocks highlight the inextricable link between the two interventions and the need to equip birth attendants with requisite skills and commodities to assess and care for every newborn. Solutions highlighted by country teams include ensuring more investment to improve workforce performance and distribution, especially numbers of skilled birth attendants, incentives for placement in challenging settings, and skills-based training particularly for neonatal resuscitation.

Underuse of modern methods of contraception: underlying causes and consequent undesired pregnancies in 35 low- and middle-income countries

STUDY QUESTION

What is the contribution of the underuse of modern methods (MM) of contraception to the annual undesired pregnancies in 35 low- and middle-income countries?

SUMMARY ANSWER

Fifteen million out of 16.7 million undesired pregnancies occurring annually in 35 countries could have been prevented with the optimal use of MM of contraception.

WHAT IS KNOWN ALREADY

Every year, 87 million women worldwide become pregnant unintentionally because of the underuse of MM of contraception.

STUDY DESIGN, SIZE, DURATION

Demographic and health surveys (DHS) of 35 countries, conducted between 2005 and 2012, were analysed.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Contraceptive use of 12 874 unintentionally pregnant women was compared with 111 301 sexually active women who were neither pregnant nor desiring pregnancy.

MAIN RESULTS AND THE ROLE OF CHANCE

An average of 96% of 15- to 49-year-old eligible women took part in the survey. When adjusted for covariates and compared with the use of MM of contraception, the use of traditional methods was associated with a 2.7 [95% confidence interval (CI): 2.3-3.4] times increase in odds of an undesired pregnancy, while non-use of any method was associated with a 14.3 (95% CI, 12.3-16.7) times increase. This corresponded to an estimated 16.7 million undesired pregnancies occurring annually in the 35 countries, of which 15.0 million could have been prevented with the optimal use of MM of contraception (13.5 million women did not use MM whilst 1.5 million women utilized MM incorrectly). Women with the lowest educational attainment and wealth quintile were 8.6 (95% CI: 8.2-9.1) and 2.6 (95% CI: 2.4-2.9) times less likely to use contraceptives compared with those with the highest level of each, respectively. Of the 14 893 women who neither desired pregnancy nor used contraception, 5559 (37.3%) cited fear of side effects and health concerns as the reason for non-use, 3331 (22.4%) cited they or their partner's opposition to contraception or religious prohibition and 2620 (17.6%) underestimated the risk of pregnancy.

LIMITATIONS, REASONS FOR CAUTION

Despite the fact that DHS are considered high-quality studies, we should not underestimate the role played by recall bias for past pregnancies. Few women report a current pregnancy in the first trimester and undesired pregnancies at that time are probably prone to under-reporting. Some terminated pregnancies may not be included in the current pregnancy group. Furthermore, covariates measured at the time of the survey may not have reflected the same covariates at the time the currently pregnant women became pregnant.

WIDER IMPLICATIONS OF THE FINDINGS

Underuse of MM of contraception burdens especially the poor and the less educated. National strategies should address unfounded health concerns, fear of side effects, opposition and underestimated risk of pregnancy, which are major contributors to undesired pregnancies.

FUNDING/CONFLICTS OF INTEREST

No external funding was utilized for this report. There are no conflicts of interest to declare.

A comparison of vital registration and reproductive-age mortality survey in Bukidnon, Philippines, 2008

OBJECTIVE

To determine the accuracy of reported maternal deaths for 2008 in a province in the Philippines.

METHODS

A reproductive-age mortality survey (RAMOS) was conducted to identify deaths of women aged 15-49 years from Bukidnon, Philippines, in 2008. Sources included various health and community reporting units. Verbal autopsies were carried out to ascertain maternal deaths.

RESULTS

The survey found 58 pregnancy-related deaths in 2008, of which 52 were maternal deaths. Of the 52, 14 were found in local civil registries but 4 were not classified as maternal deaths. No single reporting unit identified all deaths. Local civil registries provided an estimated maternal mortality ratio (MMR) of 49 per 100000 live births. The present RAMOS estimated an MMR of 209 (95% confidence interval, 191-226) per 100000 live births.

CONCLUSION

Official reports led people using the data to believe that the MMR in the province was on track for Millennium Development Goal 5 (to reduce MMR by three-quarters by 2015). The present survey showed that local civil registries missed three-quarters of all maternal deaths. All countries engaged in addressing maternal mortality reduction should consider similar approaches to improve data quality.

The economic burden of infant formula on families with young children in the Philippines

BACKGROUND

Infant formula usage places children at risk for illness and death. Studies in the United States demonstrated high economic burden, health care costs, and absenteeism of caregivers associated with formula usage. Despite high formula usage in developing countries, no economic studies were found. This study examines the financial burden of purchasing infant formula and increased health care expenditure in the Philippines, a developing country with a per capita income of $3930. The average exchange rate of the peso to the US dollar for 2003 was $1 to P52, according to Bangko Sentral ng Pilipinas (BSP).

METHODS

This is a secondary analysis of the 2003 Family Income and Expenditure Survey, a national cross-sectional multistage cluster survey of 42 094 households.

RESULTS

Almost half of Philippine families with a young child and one-third of families living on less than $2 per day purchase formula. Nationally, $260 million was spent on infant formula in 2003. Formula-buying families with young children had spent an aggregate of $143.9 million on medical care compared to $56.6 million by non-formula-buying families. After adjusting for income and nonmilk family expenditures, the average formula-purchasing Philippine family spent an additional $0.30 (95% CI: 0.24 - 0.36; r(2) = 0.08) on medical expenditure for every $1 spent on formula.

CONCLUSIONS

The economic burden from infant formula purchase and out-of-pocket medical expenditure exceeded $400 million in 2003. This cost was aside from other costs, such as absenteeism and the risk of childhood death and illness. These expenses caused an unnecessary burden on Filipino families and could instead have been invested in education and other social services.

Is unimpeded marketing for breast milk substitutes responsible for the decline in breastfeeding in the Philippines? An exploratory survey and focus group analysis

Infant mortality and morbidity risk is linked to formula usage. The proportion of Filipino infant formula users rose 6% between 2003 and 2008. It is hypothesized this rise resulted from aggressive formula industry marketing. We conducted a household survey between April and December 2006 and focus groups in April-May 2007 in The Philippines to examine the association between mothers' exposure to advertising and other information sources and formula feeding decisions. Sixteen barangays (communities) were randomly selected from three purposively selected disadvantaged rural, urban and mixed municipalities. A total of 345 households had children under 24-months age: 114, 142 and 89 households from the rural, urban and mixed municipalities, respectively. In addition 38 respondents participated in 3 focus groups of 10-15 participants each, from three selected barangays. After adjusting for education and economic indicators logistic regression analysis showed that, children were more likely to be given formula if their mother recalled advertising messages, or a doctor, or mother or relative recommended it. Those using formula were 6.4 (1.8-23.1) times more likely to stop breastfeeding before 12 months. The focus groups described how television advertisements, doctors and medical representatives enticed them to use formula. We conclude that two factors were strongly associated with the decision to formula feed: self-reported advertising exposure, and physicians' recommendations.

Immediate newborn care practices delay thermoregulation and breastfeeding initiation

AIM

A deadly nosocomial outbreak in a Philippine hospital drew nationwide attention to neonatal sepsis. Together with specific infection control measures, interventions that protect newborns against infection-related mortality include drying, skin-to-skin contact, delayed cord clamping, breastfeeding initiation and delayed bathing. This evaluation characterized hospital care in the first hours of life with the intent to drive policy change, strategic planning and hospital reform.

METHODS

Trained physicians observed 481 consecutive deliveries in 51 hospitals using a standardized tool to record practices and timing of immediate newborn care procedures.

RESULTS

Drying, weighing, eye care and vitamin K injections were performed in more than 90% of newborns. Only 9.6% were allowed skin-to-skin contact. Interventions were inappropriately sequenced, e.g. immediate cord clamping (median 12 sec), delayed drying (96.5%) and early bathing (90.0%). While 68.2% were put to the breast, they were separated two minutes later. Unnecessary suctioning was performed in 94.9%. Doctors trained in neonatal resuscitation were 2.5 (1.1-5.7) times more likely to unnecessarily suction vigorous newborns. Two per cent died and 5.7% developed sepsis/pneumonia.

CONCLUSIONS

This minute-by-minute observational assessment revealed that performance and timing of immediate newborn care interventions are below WHO standards and deprive newborns of basic protections against infection and death.

Secondary analysis of a national health survey on factors influencing women in the Philippines to deliver at home and unattended by a healthcare professional

OBJECTIVE

To elucidate factors that influence Philippine women to deliver at home and not be attended by a healthcare professional.

METHODS

Analysis of hospital data that were collected through Global Positioning System technology uploaded into the WHO HealthMapper and data on 7380 women from the Philippines Demographic and Health Survey, 2003.

RESULTS

Most of the home deliveries that were not attended by healthcare professionals occurred within 15 km of a hospital. Women who had home deliveries and were not attended by a healthcare professional were more likely to be of low educational and economic status and to reside in rural houses without basic amenities (P<0.001). Obtaining money (83.0%), transport (48.1%), and a companion (35.0%) were identified as barriers to getting treatment. Death rates of neonates born to these women were not statistically different from those of neonates who were born in a healthcare facility (OR 1.0; 95% CI, 0.63-1.57; P<0.99).

CONCLUSION

Most deliveries that were not attended by a healthcare professional occurred near a hospital. Financial barriers will need to be addressed to increase the number of deliveries in a healthcare facility. The apparent failure of hospitals to reduce newborn mortality may be related to suboptimal newborn care practices.

Formula feeding is associated with increased hospital admissions due to infections among infants younger than 6 months in Manila, Philippines

This case control study evaluates the association between hospitalization due to infection and feeding practices among infants aged >or= 3 days to < 6 months. Mothers of 191 cases hospitalized for infections and 208 healthy controls were interviewed using a standardized questionnaire documenting infant-feeding history. Results given in odds ratio and 95% confidence intervals (OR, 95% CI) were adjusted for age, education, and place of delivery. Exclusively formula-fed infants were more likely to be hospitalized for any infection (3.7, 1.8-7.5), pneumonia (3.0, 1.2-7.4), and diarrhea (10.5, 2.5-41.9) compared to exclusively breastfed infants. Infants who did not receive any breast milk were more likely to be hospitalized for any infection (3.5, 2.1-5.9), neonatal sepsis (4.9, 1.3-18.3), pneumonia (2.8, 1.5-5.4), and diarrhea (19.6, 6.5-58.6) than infants who received any breast milk. This study showed a strong positive association between the intake of formula and/or nonbreast milk supplements and the risk of hospitalization for infectious causes.

The adverse health effects of tobacco and tobacco-related products

Tobacco use continues to occur in epidemic proportions and with it, significant morbidity and mortality. One third of smokers will die prematurely of a smoking-related disease. This article reviews the adverse health effects of tobacco use so that clinicians can be aware of the benefits patients will reap when they stop using this lethal substance.