THE PROBLEM AND ITS SETTING
Neonatal stage is one of the most crucial stage for growth and development of an individual. In this stage of life, intensive care should be given to promote health of the newborn. From the time newborns are exposed to the outside environment, essential and utmost care must be rendered immediately to these delicate individuals. Evidence-based practices and care given will ensure and promote to the survival of the newborn. Approximately, there are four million global neonatal deaths occurring annually. Based on the statistics, Philippines is one of the 42 countries that account for the 90% of under-five mortality worldwide. 82,000 Filipino children under five years old die every year. 37% of them are newborn. Majority of them (3/4) die within the first two days of life, mostly due to stressful events or conditions during labor, delivery and immediate postpartum period. The current practice of handling newborns, like clamping and cutting the umbilical cord and washing the baby right after birth, have been known to actually contribute to the high incidence of neonatal deaths and illnesses in the country. Thus the need for a paradigm shifts from the prevailing standard procedures into the new protocol. (http://instantmami.blogspot.com/2010/04/doh-unang-yakap-campaign.html)
According to Duque (2009) childhood death rates in the country showed a downtrend from 1993 to 2003. The decline has slowed down in the last 10 years noted that under-five mortality rate decreased to only 32 per 1,000 live births in 2003—from 52 per 1,000 live births in 1988. Infant-mortality and child-death rates have also exhibited a similar trend over the same period.
The Department of Health (2009) launched the Essential Newborn Care program or the Unang Yakap Campaign under Administrative Order 2009-0025. This campaign aims to cut down infant mortality in the Philippines by at least half. The campaign employs Essential Newborn Care (ENC) Protocol as a strategy to improve the health of the newborn through interventions before conception, during pregnancy, at and soon after birth, and in the postnatal period. The Essential Newborn Care Protocol provides an evidence-based, low cost, low technology package of interventions that will save thousands of lives.
Former Health Secretary Francisco Duque III said that, "with the new protocol, the DOH expects a sharp cut in infant deaths to remove the Philippines from the list of 42 countries that account for 90 percent of global deaths among children below five years old." He also explained that the ENC Protocol focus on the first hours of life of the newborn The guidelines categorize procedures into time-bound, non time-bound and unnecessary procedures: Time bound procedures should be routinely performed first - immediate drying, skin-to-skin contact followed by clamping of the cord after one to three minutes, non-separation of the newborn from the mother and breastfeeding initiation.
Non time-bound intervention should only be done after the first full breastfeed. These are immunizations, eye care, Vitamin K administration and weighing. Washing must be postponed by at least 6 hours. The so-called unnecessary procedures include routine suctioning, routine separation of newborns for observations, administration of prelacteals like glucose, water formula and foot printing.
We’re launching this protocol in collaboration with the World Health Organization to help solve this newborn-mortality problem because if it is not reduced by at least half, the goal of reducing childhood mortality by two-thirds by 2015 will not be met,” he said Duque also noted that 50 percent of all neonatal and post neonatal deaths occur during the first two days of life, mainly caused by birth asphyxia (31 percent), complications of prematurity (30 percent) and severe infection (19 percent).
The new protocol stresses the provision of correct time-bound interventions, which include the immediate drying (within 30 seconds), postponing washing, delayed cord clamping, and initiation of skin-to-skin contact. Early initiation of breastfeeding (within 90 minutes after birth) is also included.
Implementation of an effective program for promotion of childbirth and newborn care practices requires understanding of the community and household traditional newborn care practices. Such information will enable the development of programs to promote culturally sensitive and acceptable change in practices.
STATEMENT OF THE PROBLEM
This research study entitled ”The Effectiveness of the Implementation of Essential Newborn Care Program of the Department of Health (DOH) in all Government Hospitals in Cabanatuan City”
Specifically, the researchers aim to answer the following questions: 1. How may the respondents be described in terms of :
2.3. Educational attainment;
2.4. Civil status;
2.5. Length of experience
2. How effective is the essential newborn care program in terms of: 2.1 Time bound procedure
2.2.1 Immediate and thorough drying
2.2.2 Early skin to skin contact
2.2.3 Properly timed cord clamping
2.2.4 Non-separation of the newborn and mother for early initiation of breastfeeding
2.2 Non time bound intervention
2.3.6 Eye care
2.3.7 Vitamin K administration and weighing
2.3.8 Unnecessary procedures
2.3.9 Routine suctioning
2.3.10 Routine separation of the newborns for observation 2.3.11 Administration of prelacteals like glucose, water formula 2.3.12 Foot printing
3. What is the implication of the study in the Nursing Profession?
There is no significant difference among the perception of the respondents in the effectiveness of the essential newborn care in Eduardo L. Joson Memorial Hospital.
This study will adopt the Erik Erikson’s psychosocial theory who claims that the infancy stage builds upon the others and focuses on a challenge or crisis that must be resolved during this stage in order to move effectively onto the next developmental stage. In implementing essential newborn care it focuses on the trust vs. mistrust which was the first step in the developmental stage.
Another theory is the Maternal Role Attainment Theory was developed to serve as a framework for nurses to provide appropriate health care interventions for nontraditional mothers in order for them to develop a strong maternal identity. This mid-range theory can be used throughout pregnancy and postnatal care, but is also beneficial for adoptive or foster mothers, or others who find themselves in the maternal role unexpectedly. The process used in this nursing model helps the mother develop an attachment to the infant, which in turn helps the infant form a bond with the mother. This helps develop the mother-child relationship as the infant grows.
The primary concept of this theory is the developmental and interactional process, which occurs over a period of time. In the process, the mother bonds with the infant, acquires competence in general caretaking tasks, and then comes to express joy and pleasure in her role as a mother.
In this context, the effectiveness of essential newborn care will be proven; lot of guidelines procedures will be done in order to help improve the health of the newborn through interventions before conception, during pregnancy, immediately after birth, and in the postnatal period. Below is the conceptual paradigm which will present the study. It presents the input-process-output when the input elements include the profile of the respondents.
The process elements include the data gathering procedure which includes interview as the main instrument use in gathering data and statistical treatment which include frequency count, percentage and weighted mean.
The output elements are the identified profile of the respondents, effectiveness of the essential newborn program and implementation of the study to nursing practice.
1. Profile of the respondents
1.3 Civil status
1.4 Educational Attainment
1.5 Length of experience
Procedures for the essential newborn care
1. TIME BOUND PROCEDURE
a. Immediate and thorough drying
b. Early Skin-to-skin contact
c. Properly timed cord clamping
d. Non-separation of the newborn and mother for early initiation of breastfeeding 2. NON TIME BOUND INTERVENTION
b. Eye care
c. Vitamin K administration and weighing
3. UNNECESSARY PROCEDURE
a. Routine suctioning
b. Routine separation of newborns for observations
c. Administration of prelacteals like glucose, water formula d. footprinting
1. Data gathering
3. Statistical Treatment
Level of effectiveness
1. Adequacy of knowledge in clinical concepts
2. Proper implementation of the different procedures of essential newborn care
Figure 1. Paradigm of the Study
SIGNIFICANCE OF THE STUDY
Basically, this research study aims to determine the effect of the essential newborn care program in Eduardo L. Joson Memorial Hospital, Cabanatuan City.
College of Nursing- since the research study focus on the respondents in ELJMH, the result of this study will help the department to improve and gain deep awareness on how effective the essential newborn care is.
Current Researcher- they will gain more knowledge regarding this Department of Health program. They will become more aware of it.
Future Researcher- this it is important to the researchers in order to understand whatever assistance they may have to enlighten those who need it with regards to their doubt about newborn care.
Mother – this will let mother know what’s the reason and importance of the essential newborn care program of Department of Health.
Nursing Administration- this will be able to determine the strength and weakness of their implementation of the essential newborn care in their hospital. This will also serve as the basis for their improvement.
Respondents- this will arm the knowledge relevant on different intervention and procedures that required for their clinical duties.
SCOPE AND DELIMITATION OF THE STUDY
This research study will be based on the actual survey conducted by the Department of Health in Eduardo L. Joson Memorial Hospital, Cabanatuan City regarding the effectiveness of the essential newborn care progam in specific area to be done on May-June 2012.
DEFINITION OF TERMS
Delivery Room- area in a hospital that is equipped for delivering babies.
Department of Health– the main health agency in the Philippines that is responsible for ensuring access to basic public health services to all Filipinos.
Effectiveness- producing a decided or a desired effect (The New Merriam-Webster Pocket Dictionary, 1961)
Essential Newborn Care- a strategy to improve the health of the newborn through interventions before conception, during pregnancy, at and soon after birth, and in the postnatal period.
Implementation- to carry out.
Immunization- stimulating the immune system, the natural disease-fighting system of the body.
Mortality rate- a measure of the number of deaths in a given population.
Neonatal death- death of a live born infant within the first 28 days of life.
Postpartum care - encompasses management of the mother, newborn, and infant during the first few days after delivery but also includes the sixth-week period after childbirth.
Time bound intervention – intervention made or carried out in a certain moment in time.
REVIEW OF RELATED LITERATURE AND STUDIES
This chapter will present the related literature and studies in order to provide information concerning the subject matter.
According to Costello and Manandhar, Paul and Beorari, (2005) Newborn care is of immense importance for the proper development and healthy life of a baby. Although childhood and infant mortality in South Asia has reduced substantially during the last decade, the rate of neonatal mortality is still high. According to one source, 60% of all neonatal deaths and 68% of the world’s burden of perinatal deaths occur in Asia. Further, although 70% of infant deaths occur during the first month of life, the policy-makers and health professionals in developing countries, until recently, neglected newborn care On the other hand, this latter group of authors maintain that the principles of essential newborn care are simple, requiring no expensive high technology equipment: resuscitation, warmth to avoid hypothermia, early breastfeeding, hygiene, support for the mother-infant relationship, and early treatment for low birth weight or sick infants. Newborn care often receives less-than optimum attention. Although, over the past 25 years, child survival programs have helped reduce the death rate among children under age 5, the biggest impact has been on reducing mortality from diseases that affect infants and children more than 1 month old.
As a result, the vast majority of infant deaths occur during the first month of life, when a child’s risk of death is nearly 15 times greater than at any other time before his or her first birth. Unlike infant and under five mortality rates, reductions in neonatal mortality have been less in the developing countries.
According to Chandrashekhar T. Sreeramareddy (2006) High-risk home delivery and newborn care practices are common in urban population also. In-depth qualitative studies are needed to explore the reasons for delivering at home. Community-based interventions are required to improve the number of families engaging a skilled attendant and hygiene during delivery. The high-risk traditional newborn care practices like delayed wrapping, bathing, mustard oil massage, prelacteal feeding and discarding colostrum need to be addressed by culturally acceptable community-based health education programmes.
According to Waldemar A. Carlo, M.D., Shivaprasad S. Goudar M.D., M.H.P.E. (2010) Major global causes of perinatal mortality are asphyxia at birth, low birth weight, and prematurity. Low-cost interventions, including training in neonatal resuscitation and “kangaroo” (skin-to-skin) care, may effectively reduce deaths from these causes; it has been estimated that introducing these interventions as a package might decrease perinatal deaths by 50% or more. A recent study that used a “before-and-after” implementation design showed that training in the World Health Organization (WHO) Essential Newborn Care course improved midwives' skill and knowledge and reduced neonatal deaths in the first 7 days after birth among low-risk women who delivered in first-level clinics in Zambia. A systematic review of the literature suggests that perinatal mortality may be decreased by training birth attendants.
Thus, wide-scale implementation and evaluation of evidence-based interventions are needed to improve perinatal outcomes, particularly in rural settings, where more than 50% of neonatal deaths occur. The First Breath study was designed to test the primary hypothesis that training birth attendants in the WHO Essential Newborn Care course and in a modified version of the American Academy of Pediatrics Neonatal Resuscitation Program would reduce the rate of death from all causes in the first 7 days after birth, among infants with birth weights of at least 1500 g who were born in rural communities in developing countries.
According to Dona Pazzibugan(2009) the current practice of handling newborns, like clamping and cutting the umbilical cord and washing the baby right after birth, have been known to actually contribute to the high incidence of neonatal deaths and illnesses in the country. Doctors are introducing a new way of caring for newborns in the first few minutes of life, which could cut by almost half the number of newborn deaths estimated at 40,000 each year.
This is a paradigm shift, was how Director Honorata Catibog, head of the Department of Health (DOH) task force on the rapid reduction of maternal and neonatal mortality, described the new program introduced by the DOH and the World Health Organization. Proponents of the Essential Newborn Care (ENC) are changing the protocol currently observed by childbirth practitioners. The ENC protocol prioritizes drying the newborn and initiating skin contact with the mother before clamping and cutting the umbilical cord. It prescribes a proper sequence of interventions that even a single health worker could perform and calls for initiating breastfeeding within the first hour of life. What should be done [immediately] after birth is to dry the baby because hypothermia can lead to several risks, Dr. Aleli Sudiacal of the DOH explained at a forum held at the Quirino Memorial Medical Center in Quezon City Tuesday. The ENC protocol is being practiced in three hospitals so far?Quirino Memorial Medical Center in Quezon City, and Fabella Memorial Medical Center and Philippine General Hospital in Manila.
Pediatric nursing provides resources for infants, toddlers, children, and their families to promote health throughout development and growth. Due to the amount a patient changes during his or her childhood, specialized care targeted to specific development points is often necessary to meet the patient's specific needs.
This chapter will presents the research methods used in data gathering, the instruments, data analysis and the statistical treatment
The research will used a descriptive method which will be suitable to determine the effectiveness of the essential newborn care. This method will be concerned with the existing conditions, each meaning and significance making adequate and accurate interpretations of data .
SUBJECT OF THE STUDY
The respondent of the study will be the staff nurses and midwives assigned in DR, NICU and OB Ward of Eduardo L. Joson Memorial Hospital, Cabanatuan City.
DATA GATHERING PROCEDURE
The data will be gathered through the use of questionnaires, observation, interview. The researchers will go to the hospital respondents and will ask permission from the Chief Nurse to be able to conduct the survey.
The study will be conducted at Eduardo L. Joson Memorial Hospital. The hospital is located in heart of Cabanatuan City, in the province of Nueva Ecija. Data gathering procedures will be completed within the hospital periphery.
The Eduardo L. Joson Memorial Hospital is located at Maharlika Highway, Barangay Bitas, Daan Sarile, Cabanatuan City, Province of Nueva Ecija, Philippines. The institution was one of the first built in the country to serve as a maternity and delivery clinic. Because of the vision and the dedication of the former Gov. Eduardo L. Joson to provide comprehensive quality medical and health care in the constituents, the institution was expanded and developed as the Nueve Ecija General Hospital.
Today the hospital is now the Nueva Ecija Provincial Hospital known after the great name of the said governor, the Eduardo L. Joson Memorial Hospital, providing comprehensive quality health care to the province and neighboring provinces.
The hospital is a duly authorized teaching and training agency of the Department of Health, with pay and service/charity wards. Providing services to Internal Medicine, Pediatrics, Surgery, Obstetrics and Gynecology, including special areas such as the 24 hours ER, OPD, Dental Services, Cancer Care Unit, Eye Center, Rehab Medicine, and Dialysis Center. It has 24 hours Laboratory Facilities, Radiology and Ultrasonography. Its Pharmacy provides the necessary medications to all the service patients for free, and the drugs and medications for the health care.
We envision Eduardo L. Joson Memorial Hospital as a local provincial hospital and a center of medical excellence in providing comprehensive medical care. MISSION:
To provide comprehensive quality health care to the people of Nueva Ecija, and the neighboring provinces, especially among the poorest of the poor. The Eduardo L. Joson Memorial Hospital stands to the principle that "Health is a basic human right.”
STATISTICAL TREATMENT OF DATA
The response of the subject in each statement in the survey questionnaires will be organized and tabulated. Various statistical treatment will be utilized such as descriptive statistics, , frequency, percentage and weigted mean. P or % = F/TF x 100
P or %=Percentage
The respondents will be given five options to select from inn evaluating the study, namely:
strongly agree (5),
and stronly disagree (1)
The respondents will ask to put a check on the column that corresponds to their answers. To arrive at the verbal description of each items, the following numerical guide to be used: Verbal DescriptionNumerical Guide
Stronly Agree4.2 – 5.0
Agree3.4 – 4.1
Fairly Agree2.6 – 3.3
Dis agree1.8 – 2.5
Strongly Dis agree1.0 – 1.79
Immediate and thorough drying| 5| 4| 3| 2| 1|
1. Position the baby in special warm unit that allows close observation | | | | | | 2. To monitor physiological changes or vital signs | | | | | | 3. Infant is dried immediately to help reduce heat loss | | | | | | 4. The first hour assessment will be done every 15 mins | | | | | | 5. Assessment will be done every 30 minutes for the next hour of baby’s Life | | | | | | 7. Do you wipe off the vernix? | | | | | |
8. Do you bathe the newborn? | | | | | |
CORD CARE CLAMPING | 5| 4| 3| 2| 1|
1. Prepare all equipment at the cord dressing. | | | | | | 2. Do you wait to stop the pulsation before you cut the umbilical cord? | | | | | | 3. Do you used 70% of isoprophyl alcohol and betadine solution in cleaning the umbilical cord? | | | | | | 4. The umbilical cord is clamped with cord clamps | | | | | |
Early Skin-to-skin contact | 5 | 4 | 3 | 2| 1|
1. Infant is monitored closely for 2-4 hours after delivery | | | | | | 2. Baby is placed in contact with the mothers skin | | | | | | 3. Identification bracelet is placed on the baby before they live the Delivery room | | | | | | 4. Foot printing of the newborn is another method of identification | | | | | | 5. Do you position the newborn in prone on the mother’s abdomen or chest? | | | | | | 6. Do you cover the newborn’s back with a dry blanket? | | | | | | 7. Do you cover the newborn’s head with a bonet? | | | | | |
Eye Care | 5 | 4 | 3 | 2 | 1 |
1. Do you wash your hands before doing the procedure? | | | | | | 2. Do you discard the first drop of the ointment before applying in the eye? | | | | | | 3. Do you apply the ointment staring from the inner canthus to outer canthus? | | | | | | 4. Do you expose the lower conjunctiva in applying the ointment? | | | | | | 5. Do you properly record the application of ointment? | | | | | |
vitamin K | 5 | 4 | 3 | 2| 1|
1. Do you properly select and clean the injection site? | | | | | | 2. Do you aspirate the plunger and is certain that the needle is injected in the muscle? | | | | | | 3. Do you administer the exact amount of vitamin K? (0.1 cc) | | | | | | 4. Do you properly dispose the syringe after the procedure? | | | | | | 5. Do you record the type and amount of medication you administered? | | | | | |
SUCTIONING | 5 | 4 | 3 | 2 | 1 |
1. Immediately after the delivery the baby’s airway is established | | | | | | 2. The time immediately after delivery is critical | | | | | | 3. Breathing is establish | | | | | |
4. Newborn breath to obtain oxygen | | | | | | 5. Fetal lungs is adequately matured that can expand | | | | | |
INITIATION OF BREASTFEEDING | 5 | 4 | 3 | 2 | 1 |
1. Focus in attention is usually directed to the newborn | | | | | | 2. To inspect and possibly breastfeed the infant | | | | | | 3. The physical condition of newborn is evaluated at birth | | | | | | 4. Do you support the newborn’s whole body? | | | | | | 5. Do you give sugar water, formula or other prelacteals? | | | | | |
VACCINATION | 5 | 4 | 3 | 2 | 1 |
1. Does the baby receive the BCG Vaccine within 24 hours? | | | | | | 2. Does the baby receive the right dose? | | | | | | 3. Do you administer the BCG vaccine at the proper site? | | | | | |