DOI: 10.1111/1471-0528.
12943
www.bjog.org
Quality maternal and newborn care to ensure
a healthy start for every newborn in the World
Health Organization Western Pacific Region
H Obara, H Sobel
World Health Organization, Western Pacific Regional Office, Manila, Philippines
Correspondence: H Sobel, World Health Organization, Western Pacific Regional Office, PO Box 2932 (United Nations Avenue), 1000 Manila,
Philippines. Email sobelh@who.int
Accepted 6 June 2014.
In the World Health Organization Western Pacific Region, the
high rates of births attended by skilled health personnel (SHP)
do not equal access to quality maternal or newborn care. ‘A
healthy start for every newborn’ for 23 million annual births in
the region means that SHP and newborn care providers give
quality intrapartum, postpartum and newborn care. WHO
and the UNICEF Regional Action Plan for Healthy Newborn
Infants provide a platform for countries to scale-up
Please cite this paper as: Obara H, Sobel H. Quality maternal and newborn care to ensure a healthy start for every newborn in the World Health
Organization Western Pacific Region. BJOG 2014; 121 (Suppl. 4): 154–159.
Introduction
The World Health Organization (WHO) Western Pacific
Region (hereafter, the Region) has 37 countries and areas
with approximately 1.8 billion people. In 2013, 23 million
(17%) of the world’s 139 million live births took place in the
Region1 (Figure 1). Of these, 21 million (91.8%) had access
to skilled health personnel (SHP) during birth while 2 mil-
lion (8.2%) did not.2 SHP include ‘doctors, nurses or mid-
wives trained in providing lifesaving obstetric care, including
giving the necessary supervision, care and advice to women
during pregnancy, childbirth and the postpartum period; to
conduct deliveries on their own; and to care for newborns’.3
Obviously, improving the health of women and newborns
equitably necessitates improving access to SHP. The Lao
People’s Democratic Republic (PDR), Papua New Guinea,
Philippines, Solomon Islands, Cambodia, Vanuatu, Marshal
Islands and Samoa have <90% of births attended by SHP.2
A newborn baby dies every 2 minutes in the Western
Pacific Region. In 2012, approximately 231 000 newborns
died within the first 28 completed days after birth, corre-
sponding to a neonatal mortality rate (NMR) of nine
deaths per 1000 live births.4 NMR varied between coun-
tries: Lao PDR 27, Papua New Guinea 24, Cambodia 18,
154
Review article
Early Essential Newborn Care (EENC). The plan emphasises
the creation of an enabling environment for the
practice of EENC; thereby, preventing 50 000 newborn deaths
annually.
Keywords Asia, maternal, neonate, newborn, Pacific, preterm,
quality of care, World Health Organization.
Philippines 14, Vietnam 12 and China 9. Newborn deaths
accounted for 55% of all children who died before the age
of five years. There are no estimates comparing NMR
attended or not attended by SHP but clearly newborn
deaths occurred in both groups.
Critical moments for improving
quality of care
Two-thirds of all newborn deaths occur in the first
three days of life,5 primarily due to complications of pre-
maturity and low birthweight, birth asphyxia and newborn
infections. International evidence suggests that there are
several opportune moments during which prevention of
newborn deaths is possible through provision of high-
quality routine care during labour, delivery and the imme-
diate postpartum period.6 Additional deaths can be pre-
vented through simple actions for prevention and care of
preterm, low-birthweight babies and sick newborns. Hence,
the focus of attention needs to include not just the time
after birth, but also the time during labour and delivery.
Hence, even where a high proportion of births are
attended by SHP there is a need to ensure that quality
essential care is provided during all these critical moments.
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Births
Access to SHP
2 million births
8.2% a
not aƩended by
SHP
SHP: Skilled Health
Personnel
23 million live
births per year
(est. 2012) b
Quality of Care
21 million births
aƩended by SHP 91.8% a
5.5 million births by C-secƟon
(24% of total births) a
Sources:
aGlobal Health Observatory, WHO, 2013
bWorld Population Prospects: The 2012 Revision, UN DESA, 2012
cTrend of Child Mortality 2013 Report, UNICEF, 2013
dCalculated using LiST, WHO, 2014
Figure 1. Births and newborns in the Western Pacific Region.
The quality of care challenge
In this article, we use the term ‘newborn care providers
(NCP)’ to include SHP, nurses, midwives, obstetricians,
paediatricians and inter-professional teams. However, NCP
may not be updated in early newborn care. Lay workers or
family members often handle the newborn, but are not
included as NCP.
As more than 90% of women and newborns have SHP
attending their births in the Region, the question increas-
ingly becomes is the quality of care good? Do the annual
21 million SHP-attended live births have universal access
to quality of maternal and newborn care during the intra-
partum and postpartum period by SHP and NCP? Do
5.5 million (24% of total) births by caesarean section
annually have appropriate maternal or fetal indications?
Not all SHP and NCP provide Early Essential Newborn
Care (EENC). EENC Core interventions are outlined in
Figure 2. Full interventions can be found in the regional
plan.7 The United Nations Children’s Fund (UNICEF)
review of the Region highlighted that the quality of
newborn care is generally substandard.8 Observational
studies9–11 identified the following common substandard
practices: 1) newborns separated from mother (either left
alone or passed to the family after the delivery); 2) fetal
heart rate not checked, partographs not completed or used
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Regional approach, a healthy start for every newborn
Newborns
Causes of newborn deaths
- Preterm birth complicaƟons
- Birth asphyxia
- Neonatal infecƟons
- Congenital abnormaliƟes
- Others
231,000 newborn
deaths per year
(est. 2012) c
One newborn dies
every two minutes
Of those, 50,000
newborn lives per year
will be saved if EENC
fully implemented.d
for decision-making; 3) the sequential order of early new-
born care procedures not followed (e.g. delayed drying, too
early cord-cutting, prioritising weighing baby rather than
skin-to skin contact/initiation of breast feeding); 4) unnec-
essary care provided, e.g. induction of labour and caesarean
section without maternal or fetal indication, routine episi-
otomies, unnecessary suction of baby, forced breast feed-
ings when a baby is not ready, i.e. before feeding cues
occur; 5) skin-to-skin contact was not provided for babies
born by caesarean section. These substandard practices can
result in death and illness of both mothers and babies. A
review of newborn care clinical protocols in six countries
in the Region demonstrated that only two were found to
reflect WHO recommendations; however, both of these
needed updating.
Description of programme
In consultation with member states and key development
partners, WHO and UNICEF jointly developed the Action
Plan for Healthy Newborn Infants in the Western Pacific
Region (2014–20) (Figure 3).7
This plan focuses on creating an enabling environment
to support SHP and NCP to provide EENC. Improving
access to SHP during birth and the QoC during and imme-
diately after birth, could save an estimated 50 000 lives in
155
 Obara, Sobel
Figure 2. Core early essential newborn care interventions.
Figure 3. Action plan for healthy newborn infants in the Western Pacific Region (2014–20).
the Region annually.12 Central to EENC is ‘The First
Embrace’—a protected and prolonged skin-to-skin cuddle
between mother and baby, which allows proper warming,
feeding and cord care. EENC also includes care of the
high-risk newborn, focusing on prevention and care of
babies born preterm, low birthweight babies and sick new-
borns.
Development of the regional plan drew on country expe-
riences, particularly those which led to changes in NCP
routine practices at scale.
156
Country case studies
Country case study 1—The Philippines
A package of sequential and appropriately timed immediate
newborn care steps called ‘The First Embrace’ was devel-
oped in 2009. This was used for both service provision
(encouraging NCP to provide essential newborn care) and
demand side (campaigning to increase client knowledge
and desirability of ‘The First Embrace’). The Department
of Health issued an administrative order to ensure that
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essential newborn care would be provided at all births. The
administrative order provides steps for implementation and
defines roles and responsibilities for all levels of the health
administration and health facilities. It defines and discour-
ages unnecessary and substandard procedures. It also sets
the path for health facility accreditation and ensures reim-
bursement for national health insurance based upon imple-
mentation of the policy and protocol. In addition, the
health professional curriculum and competencies were all
revised to reflect the latest standards.
Compared to only a low percentage of babies receiving
skin-to-skin contact in 2008,9 in 2011, a nationwide popu-
lation survey revealed that 65.6% of newborns in health
facilities were reportedly placed in skin-to-skin contact with
their mothers.13 The factors associated with the increase
may be: 1) all levels of health facilities, health administra-
tions and wider stakeholders (e.g. professional
organisations) were involved and their roles in improving
newborn care were defined; 2) a health-system-strengthen-
ing approach was taken to ensure essential drugs, commod-
ities, skilled health service providers, systems of referral,
financing, supportive supervision, monitoring and evalua-
tion of progress as far as possible. A functional health
system with continuous health system support is critical to
sustain quality implementation of EENC by NCP.
Country case study 2—Cambodia
Changing entrenched newborn care practices requires
changing the way training is done. Assessments revealed
outdated newborn care practices remained although
training had been extensive.11 A 2-day coaching pro-
gramme was conducted at local health facilities on
immediate newborn care, based on adult learning princi-
ples. Since 2011, it has been scaled up to reach more
than half of all nationwide NCP beyond SHP. In the ses-
sions, participants were first observed as they demon-
strated what they normally did, then evidence around
the practice was explored. Participants repeatedly per-
formed sequential immediate newborn care steps until
they were able to master these and could demonstrate
proficiency. Both the immediate evaluation and the
3-month supervisory visit afterwards showed remarkable
improvement in knowledge and practice.11
Current state of implementation
Newborn care programmes exist in most countries in the
Region. After the member state consultation on the regio-
nal plan (March 2013), the increased momentum resulted
in strengthening national and regional implementation. In
the 64th Regional Committee Meeting for the Western
Pacific in 2013, member states supported the regional
plan. The WHO/UNICEF joint monitoring as of January
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Regional approach, a healthy start for every newborn
2014 targeted eight countries: Cambodia, China, Lao
PDR, Mongolia, Papua New Guinea, Philippines, Solomon
Islands and Vietnam. It revealed strengthened coun-
try-level planning and implementation. EENC technical
coordination groups were formed (six yes, one planned,
one existing working group covers this), a full-time new-
born health focal person was identified in the Ministries
of Health (three yes, three planned, two no), the newborn
health situation analysis was conducted (six yes, two no),
EENC national action plan was developed (three yes, two
ongoing or planned, three no), and clinical protocols were
updated (two yes, four ongoing or planned, two no).
Although still in the early implementation phase, progress
was confirmed. Moreover, sharing the progress and the
experiences among these countries facilitates the imple-
mentation in each country because country programmes
may not want to lag behind. Monitoring will continue to
document how the national planning translates into
improved quality of intrapartum and newborn care.
Strengths
The strengths of this regional programme include the
emphasis on when, what, who and how. The programme
strategically targets the period from labour onset until
3 days after delivery (i.e. When); EENC interventions are
defined for all and for high-risk mothers and newborns
using effective interventions based on scientific evidence7
(i.e. What should be done). The programme emphasises
cost-effective interventions by discouraging common
unnecessary and substandard practices (e.g. unnecessary
induction of labour and caesarean sections) (i.e. What
should not be done). The programme encourages identifi-
cation of programme coordinators and wider stakeholders
in each country to effectively plan and implement EENC
(i.e. Who) and provides planning tools, a clinical pocket
guide and social marketing tools, which countries can easily
adapt (i.e. How). The regional programme has been
planned in consultation with member states, jointly by
WHO and UNICEF, for better coordination of implemen-
tation and monitoring at both regional and country levels.
The programme highlighted the need for the health system
to support improved access to SHP during birth and
improved access to quality newborn care by NCP, essential
drugs and commodities, effective supervision, referral, and
monitoring, infection control, and incorporation into
pre-service and in-service training curricula to ensure sus-
tainability.
Weaknesses
Measuring some target indicators presents a challenge.
Baseline data for the subnational NMR and the proportion
157
 Obara, Sobel
of births attended by SHP are not automatically available
in resource-limited countries. Therefore, the programme
focuses on improving data availability for these indicators
disaggregated by subnational level. The proposed target
indicators with disaggregated data will help in monitoring
equity in countries. Monitoring EENC implementation in
health facilities requires practice and facility observation,
exit interviews and chart/record reviews to check the qual-
ity of intrapartum and newborn care. The regional pro-
gramme includes tools and support to conduct this
monitoring. However, country-level evaluations will be
resource intensive with obvious feasibility implications.
Simplified and standardised tools and methods for measur-
ing QoC and QoC indicators for intrapartum, postpartum
and newborn care need to be further explored at global,
regional and country levels.
Opportunities
Global initiatives and the new emphasis on newborns pro-
vide opportunities to catalyse country-level political com-
mitment and momentum toward eliminating preventable
newborn deaths. Global initiatives include the United
Nations Global Strategy for Women’s and Children’s
Health, the ‘A Promise Renewed’ Initiative and the World
Health Assembly Resolutions. In particular, the recent
Every Newborn Initiative has mobilised stakeholders and
partners to collaboratively develop the global Every New-
born Action Plan to End Preventable Deaths—launched in
June 2014.14 As the first WHO region to have developed a
regional plan for newborn health in line with the global
plan, the early experiences aligned with and benefited from
these global initiatives. It likewise contributed and shared
lessons learnt from the process of development and the re-
alisation of global initiatives.
Threats
In the Region, several countries are on-track toward
achieving Millennium Development Goals (MDGs) 4 and
5.15 Consequently, policymakers and development partners
may consider MDGs 4 and 5 ‘achieved’ and may nega-
tively influence political commitment and funding for
women and newborns domestically and internationally.
However, maternal and newborn mortality rates in low-
and middle-income countries are comparable to those of
high-income countries (e.g. Japan) decades or even a cen-
tury ago. Furthermore, there is a need to improve the
QoC for all 23 million births that occur every year in the
Region, even in high-income countries. Maternal and
newborn health remain ‘unfinished agendas’. Stronger
links are needed between the movement for universal
health coverage and improving the QoC for women and
158
newborns. As tracking of resources is recommended by
the Commission of Information and Accountability for
Women’s and Children’s Health, the Independent Expert
Review Group should oversee and verify whether govern-
ments and partners commit as promised.
Conclusions
The Western Pacific Region boasts great improvements in
MDGs 4 and 5, but maternal and newborn health remain
‘unfinished agendas’. Two possible trajectories depend on
national and global commitment. Diminished commitment
will halt future improvements of women’s and newborns’
health. Alternatively, ‘a healthy start for every newborn’
means that two million currently unattended births have
improved access to SHP and all 23 million annual births
have quality intrapartum, postpartum and newborn care by
SHP and NCP.
Disclosure of interests
The authors have no conflicts of interest to disclose.
Contribution to authorship
Both authors contributed equally to the design, drafting
and critical appraisal of this article.
Details of ethics approval
Ethical approval was not required.
Funding
No funding was received for developing the manuscript.
The regional newborn health programme has been funded
by WHO, UNICEF, and grants from the Governments of
Australia and Japan.
Acknowledgements
The follow persons contributed information used in this
report: Dr Nabila Zaka (Maternal and Child Health Special-
ist, Young Survival & Development Section, UNICEF East
Asia Pacific Regional Office), Ministry of Health, Cambodia,
Department of Health, the Philippines, Country office staff
in UNICEF and WHO in the Region, Dr Mianne Silvestre
(Consultant Essential Intrapartum and Newborn Care), Dr
John Murray (Consultant Newborn Health Programme
Management), Professor Trevor Duke (Director of the Cen-
tre for International Child Health, University of Mel-
bourne), and Department of Maternal, Newborn, Child and
Adolescent Health, WHO.
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