“Unang Yakap” which literally translates to ‘First Embrace’ is the tagline for Essential Intrapartum and Newborn Care (EINC), a program of the Philippine government in cooperation with the United Nations Joint Program for Maternal and Newborn Health (JPMNH – World Health Organization and UNICEF), supported by AusAid. The program aims to decrease neonatal mortality and improve maternal health. It was designed for implementation in the Philippines but is universally applicable and should be beneficial to mothers and babies everywhere.
This series of posts is designed to help the lay person understand this life-saving initiative and will discuss the scientific evidence behind it. For this reason I will be leaving out some technical detail, but I hope it will be interesting to medical professionals and health care personnel as well.
How serious is the problem of neonatal mortality in the Philippines?
The Philippines is one of 42 countries that account for 90% of worldwide deaths in children under age 5. According to WHO statistics from 2011, 25 of every 1000 Filipino children are likely to die by age 5. Half of these children are neonates (infants 0-28 days of age). In 2011, there were approximately 2,358,000 live births in the country. This translates to over 28,000 newborn deaths in one year alone. While 12 newborn deaths per 1000 live births is an improvement from 22 per 1000 in 1990, the rate has not decreased significantly in the last 6 years. To compare, the neonatal mortality rate (NMR) in the United States is 4 per 1000 as of 2011. In Japan, it is 1 per 1000.
Prematurity, asphyxia and infection together cause over 60% of neonatal deaths, and 75% of deaths occur within the first 7 days of life, with the vast majority dying within the first 48 hours. Because of this, the Unang Yakap protocol addresses the first 7 days of life, focusing on the time immediately surrounding birth.
In the Philippines, health care is more accessible to those who can afford it. As such, one might assume that the majority of newborn deaths occur among the poorest in the country. While it is true that the rates are higher among the poor (20 per 1000), even among the richest quintile of our population, the NMR is unacceptably high at 10 per 1000 live births. The logical conclusion is that the problem is system-wide and may not be solely financial in origin.
A study by Drs. Sobel, Silvestre, Mantaring, Oliveros and Nyunt-U published in 2011 evaluated the minute-to-minute newborn care performed in 51 large hospitals in the Philippines. The data they obtained allowed them to identify and address steps in early newborn care that were likely contributing to neonatal infection and death. This resulted in the creation of the Essential Intrapartum and Newborn Care Protocol, more commonly known as “Unang Yakap”. The hope is to provide a standard of care for mothers and newborns at the time of birth regardless of where they deliver, be it a birthing center, a primary care hospital or a large referral center.
Performing these 4 Simple Steps in proper sequence at the time of birth can save newborn lives:
- Immediate Thorough Drying
- Immediate Skin-to-Skin Contact
- Appropriately-Timed Cord Clamping
- Nonseparation of newborn from mother to allow for early breastfeeding
*Edit: More than 90% of babies being born are eligible for all 4 steps – well term babies, well preterm babies, babies delivered via Cesarean Section (with minor modifications in the protocol), even multiples (twins, triplets). Babies who require immediate resuscitation or babies of mothers who are critically ill may need to be separated temporarily but can still benefit from some of these steps.
I will discuss the first 2 steps today.
IMMEDIATE THOROUGH DRYING
It used to be standard practice (and is probably still common) for a doctor or midwife delivering a baby to first take a bulb suction or catheter as soon as the baby is out, and use it to clear the mouth and nose of the newborn. This practice is no longer recommended, in the same way that we no longer hang a baby upside down by its feet or slap its back to make him/her cry. The current recommendation is to suction a baby’s mouth and nose only if it is blocked by secretions. Suctioning provides no benefit to babies who have clear airways, and may cause a slowing of the baby’s heart rate and breathing. It can also injure mucosal surfaces, increasing the risk for infection in the newborn.
Instead, experts in newborn resuscitation recommend immediate thorough drying (wiping off any moisture with a dry, warm blanket, taking care to leave the vernix -that white, cheesy substance covering a newborn – intact) for a full 30 seconds as the first step to be performed when a baby is born. Drying stimulates breathing and prevents hypothermia, which can lead to numerous undersirable consequences in a newborn, including infection, breathing abnormalities and a delayed adjustment of the blood circulation. With drying alone, 95% of newborns will breathe normally at birth. Less than 5% of babies will require further resuscitation and even so, immediate and thorough drying needs to be done before anything else can follow.
IMMEDIATE SKIN-TO-SKIN CONTACT
Most women who have given birth in a hospital in the past few decades will remember that their baby was immediately wrapped in a blanket and put in a bassinet or taken away to the nursery. Many women who are having babies in the Philippines today may be shocked when instead of doing that, their physician or midwife places their naked newborn on their tummy or chest immediately after the baby is wiped dry.
While it is commonly thought that the sole benefit of skin-to-skin contact between a mother and her newborn is to promote mother-infant bonding, current evidence shows that the benefits of immediate skin-to-skin contact extend way beyond forging an emotional connection. The act reduces infant crying, keeps the baby warm, and promotes successful breastfeeding. It exposes babies to helpful bacteria on the mother’s skin, helps them maintain their temperature, and keeps their blood sugar levels from dropping. In the past, it was thought that this practice could wait until the mother and baby were both declared ‘stable’, but we now know that doing this immediately actually helps ‘stabilize’ the baby.
To read on to Part 2, click here https://drzeka.wordpress.com/2013/08/27/unang-yakap-part-2/