Howard Sobel

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.

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 ≥ 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. J Hum Lact. 26(1):19-25.

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 partners 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.

Quality at the centre of universal health coverage

The last decade of the MDG era witnessed substantial focus on reaching the bottom economic quintiles in low and middle income countries. However, the inordinate focus on reducing financial risk burden and increasing coverage without sufficient focus on expanding quality of services may account for slow progress of the MDGs in many countries. Human Resources for Health underlie quality and service delivery improvements, yet remains under-addressed in many national strategies to achieve Universal Health Coverage. Without adequate investments in improving and expanding health professional education, making and sustaining gains will be unlikely. The transition from the Millennium Development Goals (MDG) to the Sustainable Development Goals (SDG), with exciting new financing initiatives such as the Global Financing Facility brings the potential to enact substantial gains in the quality of services delivered and upgrading human health resources. This focus should ensure effective methodologies to improve health worker competencies and change practice are employed and ineffective and harmful ones eliminated (including undue influence of commercial interests).

Implementing a national policy for hepatitis B birth dose vaccination in Philippines: Lessons for improved delivery

BACKGROUND An estimated seven million Filipinos (10-12% of the population) are chronically infected with hepatitis B virus (HBV). Achieving high birth dose coverage with hepatitis B vaccine is critical for achieving the World Health Organizations Western Pacific Regional goal of reducing the prevalence of chronic HBV among children 5 years of age to <2% by 2012. METHODS Seven months after the Philippines adopted a hepatitis B vaccine birth dose policy, hospitals with the highest number of deliveries were invited to participate in an assessment of implementation of the birth dose policy. Additionally, in metro Manila birth dose coverage was estimated before and after conducting a training workshop and supervisory follow-up for practitioners conducting home deliveries or deliveries at lying-in clinics. RESULTS Of the countrys largest 150 hospitals in terms of authorized bed capacity, 85 (56%) were included in this assessment. These hospitals had 55,719 deliveries during July-September 2007. Of these, 54% infants had a documented birth dose; however, only 22% were vaccinated within 24h of delivery. Having a copy of the hepatitis B vaccine vaccination policy (prevalence odds ratio [pOR]=4.7, 95% confidence interval [CI]=1.2-18.0), having standing orders pOR=4.8, 95% CI=1.3-18.1 and providing training pOR=18.9, 95% CI=5.3-67.0 were associated with >50% birth dose coverage in a hospital. In metro-Manila, regardless of place of birth, the training workshop and supervisory follow-up significantly improved hepatitis B vaccine administration within 24h after birth, increasing from 19% before to 74% after the training workshop and follow-up. CONCLUSIONS Experience in the Philippines showed that actions by national, regional and health facility policy makers such as establishing national policies, distributing detailed and specific guidelines, conducting effective training and supervision, and having hospital standing orders substantially increased hepatitis B vaccine birth dose coverage.

People's Initiative to Counteract Misinformation and Marketing Practices: The Pembo, Philippines, Breastfeeding Experience, 2006

The Philippines is among 42 countries accounting for 90% of under 5-year-old deaths. Only 16% of 4 to 5 month old Filipinos exclusively breastfeed. In 2006, almost

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

100 million was spent advertising formula in the Philippines. To counter widespread misinformation and improve breastfeeding a peer counseling intervention was developed to target mothers with infants less than 2 months of age who were not exclusively breastfeeding or had difficulty breastfeeding. Participants received 3 peer counseling visits. At baseline and 3 weeks later, 24-hour food recalls for infants were collected. The number of exclusively formula-fed infants decreased seven-fold (P < .001). Mixed-fed infants decreased 37% (P < .001). Overall, of the 148 nonexclusively breastfeeding infants, 69.5% had changed feeding methods after 3 home visits, 76% of whom to exclusive breastfeeding. Community-based peer counseling was associated with a drastic improvement of exclusive breastfeeding practices. This intervention evolved and became sustainable by engaging political figures, cities, and communities throughout the process. In 2 years, the Department of Health, World Health Organization (WHO) program has scaled up to improve health service delivery for 161 612 persons in depressed urban communities in the Philippines. J Hum Lact. 25(3):341-349.

Working Mothers of the World Health Organization Western Pacific Offices: Lessons and Experiences to Protect, Promote, and Support Breastfeeding

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

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

Optimal breastfeeding saves lives. However, suboptimal breastfeeding is prevalent, primarily resulting from inappropriate promotion of infant formula and challenges of working mothers to continue breastfeeding. The article aims to determine the extent to which World Health Organization (WHO) policies protect, promote, and support breastfeeding women working at the WHO, Western Pacific Region. An online survey targeted all female WHO and contractual staff in all country and regional offices, who delivered a baby between July 24, 2008 and July 24, 2013. Respondents advised on how the worksite could better support breastfeeding. Thirty-two female staff from 11 of the 12 WHO offices within the Western Pacific Region responded. “Returning to work” (44%) and “not having enough milk” (17%) were the most commonly reported reasons for not breastfeeding. Eighteen (56%) reported using infant formula and 8 (44%) reported that the product was prescribed. Among the suggestions given to better support breastfeeding, 10 (32%) recommended having a private room with a chair, table, electric outlet, and refrigerator. The findings show that women working at the WHO face similar challenges to mothers outside the WHO. Based on the findings, we recommend the following: (1) provide prenatal/postpartum breastfeeding counseling services for employees; (2) establish breastfeeding rooms in country offices and regularly orient staff on agency policies to protect, promote, and support breastfeeding; (3) annually celebrate World Breastfeeding Week with employees; (4) encourage other public and private institutions to conduct online surveys and elicit recommendations from mothers on how their workplace can support breastfeeding; and (5) conduct a larger survey among UN agencies on how to better protect, promote, and support breastfeeding.

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

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