SHORT REPORT

Childbirth and Early Newborn Care Practices in 4 Provinces in

China: A Comparison With WHO Recommendations
Tao Xu,a Qing Yue,a Yan Wang,a John Murray,b Howard Sobelb

In the 10 hospitals studied, we found that hospital policies, protocols, and interventions only partially align with
WHO early newborn care recommendations, and that many hospitals still use outdated and non-medically
sound practices.

ABSTRACT
Objectives: As a part of the process of implementing Early Essential Newborn Care (EENC) in China, which are evidence-based inter-
ventions recommended by the World Health Organization (WHO), we sought to understand whether current hospital policies are con-
sistent with WHO-recommended standards and what factors influence their use. Data from the study will help inform policy changes
needed to support the introduction of evidence-based childbirth and early newborn care practices effectively and to inform further scale
up of EENC nationwide.
Methods: Ten randomly selected hospitals in 4 early-introducing provinces participated in the study. We collected data from 20 simu-
lated delivery scenario observations and focus group discussions and individual interviews with 10 hospital management staff. Policies,
protocols, and guidelines related to childbirth and newborn care practice were also collected and reviewed at each hospital.
Additionally, a survey was emailed to 15 childbirth and newborn experts from the 4 selected provinces and completed by 13. Data
were compared with WHO EENC evidence-based standards to calculate the agreement rates. Barriers to introducing evidence-based
guidelines were identified in focus groups and key informant interviews, then combined into common categories.
Findings: Hospital policies were not consistent with WHO recommendations in 10 (59%) of the 17 delivery and early newborn care
practices. Delayed cord clamping was recommended by 30% of hospital protocols and prolonged skin-to-skin contact by 13%, neither
of which were observed in the delivery simulations. Kangaroo mother care (KMC) for stable preterm babies was required in only 17% of
the hospitals; no preterm babies had KMC initiated, with all immediately separated from their mothers and admitted to neonatal inten-
sive care units. Newborn resuscitation equipment was required to be placed within 2 meters of the delivery bed in 84% of hospital
protocols, but was prepared in only 40% of cases. Immediate drying after birth was required in 48% of hospital protocols, but was
initiated in only 20% of observed cases.
Conclusions: Current childbirth and early newborn care policy and practice in China is not aligned with WHO recommendations for
some major interventions. To make it easier and safer for hospital workers to practice EENC, expert working groups and national pol-
icies must be established to address inconsistencies and cultural beliefs and provide a strong, evidence-based set of guidelines for hos-
pitals and health workers to follow.

INTRODUCTION represented over half of all child deaths.1 Despite these

W ith an estimated 16 million babies born annually, reductions, the number of children under 5 dying each
China has achieved remarkable progress reducing year remains close to 200,000, the majority of whom
deaths among children under 5 over the past 2 decades. are born in remote rural areas without adequate care
Between 1991 and 2015, the under-5 mortality rate of and support. In 2011, the World Health Organization
Chinese children declined by 80% from 79.2 to 10.7 per (WHO) estimated that institutionalizing simple, low-
1,000 live births and infant mortality declined from cost interventions during childbirth and the early
50.2 to 8.1 per 1,000 live births.1 By 2015, the newborn newborn period could prevent at least 22% of reported
mortality rate was 5.4 per 1,000 live births, which Chinese newborn deaths.2
Since the World Summit for Children in 1990, China
a
National Center for Women and Children's Health, Chinese Center for Disease has invested in strengthening policy and legislation for
Control and Prevention, Beijing, China. improving the child health system3,4 by enacting the
b
Reproductive, Maternal, Newborn, Child and Adolescent Health, Division of Law of the People's Republic of China on Maternal and
Noncommunicable Diseases and Health through Life-Course, World Health
Organization, Regional Office for the Western Pacific, Manila, Philippines. Infant Health Care5 and developing the Measures for the
Correspondence to Tao Xu ([email protected]). Implementation of Law of the People's Republic of China on

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Maternal and Infant Health Care6. Based on these areas of policy, planning, coordination, and pro-
2 documents, the central government developed gram implementation. This has included local ad-
specific maternal and child health (MCH) action aptation and endorsement of the Early Essential
plans—the National Program of Action Plan for Newborn Care Clinical Practice Pocket Guide,10 the
Women Development in China (2011–2020)7and the coaching/training of health facility staff on EENC,
National Program of Action Plan for Children and institutionalization of approaches to improve
Development in China (2011–2020)7—that identify the quality of practices in hospitals related to
10-year obj-ectives, main indicators to measure childbirth and the immediate newborn period.11
and meet, and strategies for improving women's In 2015, the National Health and Family
and children's health, education, protection, and Planning Commission (NHFPC) in China began
rights. While these documents covered a wide prioritizing the introduction of EENC, beginning
range of issues, quality early essential newborn with improving quality of hospital care in 4 early-
care (EENC) was not mentioned. implementation provinces. Preliminary discus-
To improve quality Progress on improving the quality of care sions with senior hospital staff found that hospital
of care during around delivery and in the early newborn period newborn health protocols often vary considerably
delivery and in the has been slower than other aspects of child health within and across facilities. Prior to the implemen-
newborn period, and recognized as an area that needs renewed tation of EENC in China, we sought to first under-
8 countries attention.8 To that end, in 2013, China and 7 other stand what protocols were being used in hospitals
collaborated with countries, collaborated with the WHO Western in the 4 early-implementation provinces, whether
WHO/WPRO to Pacific Regional Office (WHO/WPRO) to develop current policies were consistent with WHO-
develop a and adopt the Action Plan for Healthy Newborn recommended standards, and what factors influ-
Infants in the Western Pacific Region (2014–2020).9 ence their use. The aim of these data was to inform
regional action
This plan outlines an approach for implementing the policy changes needed to support the intro-
plan to implement
and scaling up a package of evidence-based EENC duction of evidence-based delivery and early new-
and scale up EENC
interventions recommended by WHO that have born care practices effectively and to inform scale
interventions.
been demonstrated to reduce newborn mortality up to other regions of the country.
from the 3 most important causes: prematurity,
birth asphyxia, and sepsis (Table 1). The EENC
approach focuses on improving the quality, reach, METHODS
and demand for facility-based maternal and new- We conducted the study between December
born services using a systems-based approach to 2015 and April 2016 using observations of simu-
improve health worker practices.10 All 8 of the lated deliveries, focus group discussions with the
countries have since taken important steps in the simulation participants, individual interviews

TABLE 1. Core EENC Interventions

Population Intrapartum Care Newborn Care

All mothers and The First Embrace  Labor monitoring (partograph)  Immediate drying
newborn infants  Immediate skin-to-skin contact
 Appropriately timed clamping and cutting of the cord
 Exclusive breastfeeding
 Routine care (eye care, vitamin K, immunizations,
weighing, and examinations)
At-risk mothers and Preterm and LBW Preterm labor  Kangaroo mother care
newborn infants infants Elimination of unnecessary inductions  Breastfeeding support
and cesarean deliveries  Immediate treatment of suspected infection
 Antenatal steroids
 Antibiotics for preterm PROM
Sick newborn infants Obstructed/prolonged labor Not breathing at birth
Fetal distress  Resuscitation
 Assisted delivery Suspected sepsis
 Cesarean delivery  Antibiotic treatment

Abbreviations: EENC, Early Essential Newborn Care; LBW, low birth weight; PROM, pre-labor rupture of membrane.

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with hospital management staff, a key informant

survey mailed to Neonatal Resuscitation Program
(NRP) instructors, and a desk review of hospital
protocols.

Study Sites
The study was conducted in Beijing, Shaanxi,
Sichuan, and Inner Mongolia provinces. The
NHFPC chose these 4 provinces because they are
representative of provinces with different eco-
nomic development statuses. In each province,
1 city and 1 county within this city were random-
ly selected. At each level—provincial, city, and
county—1 hospital was randomly selected, for a
total of 10 selected hospitals. Since Beijing is a
municipality directly under the central govern- A simulated delivery scenario of a breathing baby was conducted in 1 hos-
ment, only city- and county-level hospitals were pital in Sichuan, China. © 2016 Tao Xu/National Center for Women and
selected. Children's Health, Chinese Center for Disease Control and Prevention

Simulated Delivery Observations, Focus

Group Discussions, and Interviews recommendations and probed why staff used Simulated
We conducted 2 simulated deliveries in each of the these practices, what factors influenced the delivery scenarios,
10 hospitals selected, for a total of 20 simulated practices, what barriers impeded changing prac- followed by focus
deliveries, and health care provider focus groups tices, and how compliance with standards was group discussions,
and interviews to assess current practices. We monitored. were used to
used scenario assessments instead of actual deliv- In addition to the simulated delivery observa- assess current
eries for 2 reasons: (1) we could not get permission tions and the focus group discussions, 1 hospital hospital and
from pregnant women to observe their actual management staff at each hospital was inter- health worker
deliveries, and (2) we believed that using simu- viewed (N=10) about how the implementation practices without
lated cases would be an easier and less stressful of delivery and early newborn care policies was jeopardizing the
way for health care providers to demonstrate their conducted, including how the hospital monitored health and safety
routine practices. adherence to hospital protocols and what was of delivering
Six staff members—2 midwives, 2 obstetricians, done if protocols were not followed. All observa- mothers and their
and 2 pediatricians—were selected randomly in tions, focus group discussions, and individual newborns.
each hospital to join a delivery simulation session interviews were recorded for data management
and a focus group discussion. The sessions were and analysis.
conducted in a delivery room, or a room set up like
a delivery room, and had 2 components. First, the
facilitator asked a midwife and an obstetrician to Key Informant Mail Survey
demonstrate management of a routine normal A survey was emailed to 15 national NRP instruc-
delivery—dividing tasks according to the routine tors in the 4 provinces to collect data on delivery
protocol—using a manikin infant, delivery kits, and early newborn care policies, protocols, and
and other delivery room supplies. The facilitator guidelines. The group of NRP instructors included
observed and scored the tasks performed using a national and provincial health bureau managers,
standard EENC skills review method and checklist, MCH program officers, and childbirth and new-
with 1 participant playing the role of the mother born care specialists. A survey questionnaire was
and the others conducting the delivery.12,13 Core developed and distributed via email; respondents
practices reviewed were based on WHO recom- were asked to return the completed survey via
mendations and included in the EENC clinical email. The questionnaire asked respondents to
coaching approach.14 The practice scenario was compare WHO recommendations on key practices
repeated for management of a non-breathing to current childbirth and newborn care practices,
baby requiring resuscitation. Second, facilitators policies, and recommendations; describe how
conducted a focus group discussion to identify adherence to protocols within hospitals is
steps that were inconsistent with WHO monitored; and identify perceived barriers and

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challenges to implementing WHO-recommended returned. Respondents included 5 pediatricians,

guidelines. 3 obstetricians, 3 midwives, and 2 MCH program
officers.
Desk Review of Hospital Protocols The number of annual deliveries and the
At each of the hospitals, current policies, proto- number and type of staff available to provide
cols, and guidelines related to childbirth and delivery services varied greatly between hospitals
newborn care practice were also collected and (Table 2). In 9 of the hospitals, at least 1 midwife
reviewed. The documents reviewed included and 1 obstetrician are routinely present at each
both practice guidelines (e.g., clinical procedures delivery, with the midwife practicing delivery
and standards) and management procedures under the supervision of the obstetrician. At
(e.g., frequency of reporting of data, accreditation 1 hospital, no midwives were available prior to
mechanisms). If protocols referred to primary 2015 and deliveries were conducted by obstetri-
sources, such as medical society recommenda- cians. Most hospitals had at least 1 nurse to help
tions, textbooks, or adapted international guide- in the delivery room. Pediatricians were usually
lines, these were also reviewed. only present in delivery rooms for high-risk preg-
nancies or if they were called to help with emer-
Data Analysis gency cases.
Data on the policies, protocols, and guidelines
were extracted and entered into a Microsoft Comparison of Hospital Protocols and
Office Excel 2013 file that allowed comparisons Practices With WHO Recommendations
with WHO EENC evidence-based standards. A review of hospital protocols—by self-report
Agreement rates for each practice or intervention through the survey and onsite review by study
Hospital protocols were calculated by dividing the number of hospi- staff—revealed that hospital protocols were con-
and observed tals with protocols consistent with WHO recom- sistent with WHO guidelines for 7 (41%) of the
practices were mendations by total number of hospitals. Each 17 delivery and early newborn care practices,
consistent with health care provider focus group discussion and including routine use of the partograph, use of
only 41% of interview was transcribed into a Microsoft Word corticosteroids for women of 24 to 34 weeks' ges-
the 17 WHO- 2013 file. Focus group and interview notes and tation at risk of preterm birth, optimal timing
recommended transcripts were reviewed to summarize and com- technique for cord cutting, use of oxytocin for
delivery and early pare the hospital protocols with WHO recommen- active management of the third stage of labor, rou-
newborn care dations. Findings on accreditation mechanisms for tine administration of hepatitis B and bacillus
practices. current hospital protocols and perceived barriers Calmette-Guérin vaccines, and delayed bathing
to change current protocols were summarized until at least 24 hours after birth (Table 3).
across all hospitals and combined into common Despite this, we also discovered that protocols for
categories. 10 practice areas were not consistent with WHO
recommendations. None of the hospitals had poli-
Ethical Approval cies on immediate and thorough drying after birth,
Institutional ethics approval to conduct the study delayed cord clamping, and dry-cord care. Less
was obtained from the institutional review board than 50% of hospitals had a policy on birth posi-
at the National Center for Women and Children's tion and companion of choice during childbirth
Health at the Chinese Center for Disease Control (38%), immediate and thorough drying after birth
and Prevention (NCWCH). Informed consent was (48%), delayed cord clamping (30%), prolonged
obtained from all health care providers participat- skin-to-skin contact (13%), delayed routine care
ing in observations and interviews. until after the first breastfeeding (17%), and kan-
garoo mother care (KMC) for all newborns less
than 2000 grams (17%).
RESULTS
The practices of hospital staff who were
Background Characteristics of Study observed in routine delivery scenarios were con-
Hospitals sistent with WHO recommendations in the same
Ten hospitals from 4 provinces were sampled. 7 practices areas noted for hospital protocols
Site visits with desk review of policies, focus group (Table 3). The other 10 practice areas were never
discussions, individual interviews, and delivery or rarely practiced in observed delivery scenarios,
observations were conducted at those hospitals. regardless of the hospital protocol. Practices
Thirteen of 15 mail survey questionnaires were never conducted in practice scenarios included

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TABLE 2. Characteristics of Hospitals Included in the Study, China, December 2015

No. of Deliveries No. of No. of No. of

Province and Hospital in 2014 Obstetricians Pediatricians Midwives

Beijing
Beijing MCH 17,250 68 15 65
Beijing University People's 2,343 16 17 12
Shaanxi
Shaanxi Provincial MCH 13,338 111 81 55
Shangluo City MCH 1,845 18 12 9
Luonan County MCH 2,653 6 5 8
Sichuan
Sichuan Provincial MCH 6,327 114 59 28
Liangshan City MCH 1,818 35 30 23
Inner Mongolia
Inner Mongolia Provincial MCH 8,522 33 16 28
Wuhai City MCH 6,064 25 18 3
Nanhai County 394 6 4 4

Abbreviation: MCH, maternal and child health.

immediate and thorough drying after birth, imme- discussions with simulation participants and key
diate skin-to-skin contact of adequate duration, informant interviews with NRP instructors. The
delayed cord clamping, absence of routine suction, results are summarized below.
and delaying routine tasks until after the first
breastfeeding. Although delayed cord clamping
was recommended by 30% of hospital protocols Clinical Protocols and Guidelines
and prolonged skin-to-skin contact by 13%, nei- Each province has developed an MCH plan and
ther were practiced in any case observations at the the measures for administration of midwifery
10 hospitals, with hospital staff completing routine techniques guidelines. These provincial policies
care (eye care, weight, and height) immediately af- regulate the certification of delivery services,
ter birth before skin-to-skin contact. Similarly, required preservice and in-service trainings and
KMC for stable preterm babies was required in qualifications for providers, accreditation mecha-
17% hospitals; no preterm babies had KMC initi- nisms and regulations, basic equipment and
ated, with all immediately separated from the facility requirements, and content of services for Key barriers to
mother and admitted to neonatal intensive care the different levels of hospitals. However, none improving
units. Newborn resuscitation equipment was of these guidelines provide detailed clinical prac- hospital protocols
required to be placed within 2 meters of the deliv- tice standards or protocols on immediate child- included the lack
ery bed in 84% of hospital protocols but was only birth and early newborn care, leaving hospitals of a standardized
prepared in 40% of cases. Immediate drying evidence-based
to look to other resources. For example, the
(within 5 seconds of birth) was required in 48% of set of clinical
Guide for Prevention and Treatment of Postpartum
hospital protocols but was initiated in only 20% of
Hemorrhage15, developed by the Chinese Medical protocols and
observed cases.
Society, provides detailed protocols for techni- guidelines,
ques such as cord clamping and the use of oxyto- supported by
Barriers to Improving Hospital Protocols for cin, and an NRP guideline was developed for the peer-reviewed
Delivery, Childbirth, and Early Newborn NHFPC-led China NRP program. As a result, par- literature and
Care ticipants indicated that hospitals have to develop aligned with a
Several potential barriers to introducing evidence- their own protocols based on the textbooks and system of
based guidelines were identified in focus group guidelines available to them, which, in turn, has evaluation.

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TABLE 3. Number and Proportion of Hospitals With Delivery and Immediate Newborn Protocols and Practices Consistent With WHO
Recommendations by Assessment Method, China, December 2015

Protocol Protocol
Self-Report Onsite Observed
via Mail Hospital Delivery
Survey Review Practice
(n=13) (n=10) (n=10)
Intervention No. (%) No. (%) No. (%)

Companion and position of choice for all deliveries 5 (39) 3 (30) 3 (30)
Maternal and fetal monitoring during labor including use of the partograph 13 (100) 10 (100) 10 (100)
Corticosteroids for women of 24 to 34 weeks' gestation who are at risk of preterm delivery 13 (100) 10 (100) 10 (100)
Bag and mask resuscitation kit available for every delivery, positioned within 2 meters of delivery bed 11 (85) 6 (60) 4 (40)
Drying started within 5 seconds after birth 7 (54) 4 (40) 2 (20)
Dried the baby thoroughly (wiped the eyes, face, head, front, back, arms, and legs) 0 (0) 0 (0) 0 (0)
No routine suctioning 0 (0) 0 (0) 0 (0)
Delayed cord clamping performed 1 to 3 minutes after birth, after cord pulsations have stopped 4 (31) 3 (30) 0 (0)
Clamp/tie placed at 2 cm, forceps at 5 cm from umbilical base 13 (100) 10 (100) 10 (100)
No placing substances on the cord stump 0 (0) 0 (0) 0 (0)
Skin-to-skin contact for a minimum of 90 minutes for newborns without complications 3 (23) 0 (0) 0 (0)
Intramuscular oxytocin given to mother within 1 minute 13 (100) 10 (100) 10 (100)
All routine newborn care (e.g., eye care, vitamin K, immunizations, and examinations) delayed until after 2 (15) 2 (20) 0 (0)
a full breastfeeding
First dose of hepatitis B vaccine given within 24 hours of birth 13 (100) 10 (100) 10 (100)
Single dose of BCG vaccine given within 24 hours of birth 13 (100) 10 (100) 10 (100)
No bathing of the newborn until at least 24 hours after delivery 13 (100) 10 (100) 10 (100)
KMC for preterm babies weighing 2000 g at birth, including feeding with breast milk and monitoring 3 (23) 1 (10) 0 (0)
for complications

Abbreviations: BCG, bacillus Calmette-Guérin; KMC, kangaroo mother care.

led to inconsistent protocols and practices across recommendations and Medical Society guidelines
the different hospitals. because these are officially sanctioned, and have
legal status in case of medical disputes.

Systems of Accreditation and Legal Status of

Protocols Understanding of the Evidence Base Supporting
While national- and provincial-level MCH service New Practices
evaluation standards are currently available, they Peer-reviewed journal articles used for WHO
only focus on basic principles and requirements, GRADE recommendations, for example, are felt
not core evidence-based practices. Hospitals are to be important to explain key practice steps such
evaluated every 3 or 4 years by provincial author- as prolonged skin-to-skin contact, delayed cord
ities. If the basic standards are not met, the hospi- clamping, non-use of suction except for non-
tal may be prohibited from providing MCH breathing babies born with meconium staining
services the following year. If an individual staff and dry cord care. This is particularly important
member is found not to be practicing protocols, for explaining why new evidence-based recom-
he or she may be disciplined by verbal criticism, mendations are different from those used previ-
deduction of wages, suspension of license, or a ously. For example, the previous duration for
lawsuit, depending on the severity. Most hospital skin-to-skin contact recommended in baby-
staff believe they should follow domestic textbook friendly hospital guidelines was 30 minutes, not

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90 minutes. Similarly, many staff believed that Since 2013, the Chinese NHFPC has been
applying disinfectants and covering the cord working with the United Nations Children's Fund
stump is important to prevent sepsis, and would (UNICEF) China to develop a newborn survival
like to see relevant data on this issue. In two hos- framework and service package, as the govern-
pitals, staff were concerned that mothers may not ment response to the WHO and UNICEF Every
be able to safely hold babies in skin-to-skin contact Newborn Action Plan. The central and provincial
and may drop them; in some cases there was con- health authorities have developed various policy
cern that this position may be associated with an documents that, for example, regulate the certifi-
increase in the risk of asphyxia. cation of delivery service, required preservice and
in-service trainings and qualifications for pro-
viders, accreditation mechanisms and regulations,
Cultural Beliefs and Practices
requirements for basic equipment and facilities,
A number of cultural practices and beliefs
and a description of services for different levels of
held by families, particularly grandparents, pre-
hospitals. In May 2018, the NHPFC issued the
vent evidence-based practices from being applied
Healthy Child Action Plan (2018–2020),17 and new-
including early separation of the newborn from
born health is one of the key areas that needs to
the mother so the newborn can be shown to other
be strengthened. These government documents
family members, concerns that skin-to-skin con- do not, however, provide detailed technical proto-
tact with the mother is dangerous, a desire to cols on childbirth and newborn health care inter-
bathe the newborn early, and beliefs that ventions. Instead, hospitals have had to adopt and
keeping the cord stump uncovered will allow develop their own technical protocols based on
“cool breezes” to pass through the cord stump textbooks, medical society guidelines, or experi-
into the newborn's body and cause illness. ence learned from others. As a result, these hospi-
tal protocols were inconsistent in their scientific
Facility Support for New Practices foundations and clinical procedures. In addition,
Maintaining skin-to-skin contact for 90 minutes, although a description of childbirth and immedi-
or until the first breastfeeding, usually requires ate newborn care was available in the hospital
the assistance of postnatal care staff who may not documents we examined, the technical proce-
be familiar with the how and when to initiate each dures were fragmented and not presented or
Many of the
technique and for how long. Breastfeeding coun- implemented in a systematic manner. To address
technical
seling, in particular, is essential for initiating the policy and practice inconsistencies within and
childbirth and
first feed. In some cases, staff members were across hospitals in the country, a national guide
newborn health
concerned that beginning new practices would on childbirth and early newborn care is needed.
In 1988, less than half of all women in China care protocols
increase the workload for midwives or nursing
gave birth in hospital; within 20 years, hospital used by the
staff and wanted clarification on how responsibil-
births became almost universal.18 This change is, hospitals studied
ities would change.
in part, due to the government discouraging com- were limited,
munity midwifery and introducing a safe mother- outdated, and did
DISCUSSION hood program that encourages hospital delivery in not use a strict
Our findings suggest that although China has no 2000.19 The Chinese NHFPC is now focusing on evidence-based
national EENC guidelines, many childbirth and improving the quality of in-hospital maternal and guideline
newborn health care protocols and practices were child health care, especially the quality of care development
evident in various documents at the hospital during and immediately after birth. WHO esti- process.
level. However, technical protocols related to mates that full implementation of EENC in the
childbirth and newborn health care were frag- Western Pacific Region could prevent at least
mented, outdated, and developed through a non- 50,000 newborn deaths each year.9 Central to
scientific guideline development process, and over EENC is the concept and practice of “The First
half were not consistent with WHO guidelines. Embrace,” a protected and prolonged skin-to-skin
Because the EENC recommendations are new cuddle between mother and newborn, which
and not included in current protocols, facilities allows proper warming, feeding, and cord care.
were not expected to adhere to them. To introduce The EENC protocol also includes the care of high-
EENC in China, implementers must recognize risk newborn infants, including preterm and low
the need to identify necessary support for and birth weight babies, and of sick newborn infants.10
changes in hospital policy, organization, accredi- Despite of these proven effective interven-
tation mechanisms, and cultural beliefs. tions, many inappropriate interventions are still

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practiced in hospitals that interfere with the baby's must also need to be recognized, as they can influ-
ability to adapt and feed well, such as unnecessary ence how and why parents make certain deci-
suctioning, immediate cord clamping, and delayed sions. Thus, capacity building activities should go
drying. These outdated practices increase the risk beyond training and focus on coaching, which
of delayed fetal-to-newborn circulatory adjust- focus on methods for improving awareness
ments, infection, breathing problems, hypother- of the importance of evidence-based practices.
mia, anemia, acidosis, coagulation defects, brain Last, insufficient coordination between obstetric
hemorrhage, and trauma.9 Many newborns are and pediatric care complicates newborn care.21
distressed, hypothermic, and exposed to danger- Changes in facility support and the organization
ous bacteria because they are separated from their of work are required to support revised practices
mother.10 The first breastfeeding is often delayed and to ensure that new practices are understood
because of an incorrect sequencing of actions and adopted by all. For example, closer collabora-
taken immediately after birth.7 In our study, less tion is needed between staff present at delivery
than half of the hospital protocols we reviewed who may currently divide or share tasks, particu-
were consistent with WHO recommendations for larly those tasks that obstetrics or midwifery staff
procedures related to childbirth and immediate may not traditionally feel is their responsibility,
newborn care, such as immediate drying after such as identifying whether a newborn is stable
birth, no routine suctioning, delaying cord clamp- and able to be placed into immediate skin-to-skin
ing, skin-to-skin contact, no placing substances on contact and starting immediate newborn bag and
the cord stump, and KMC for stable preterm mask resuscitation for non-breathing newborns.
babies. In addition, the abovementioned key Neonatal deaths in the Western Pacific Region
practice areas were never or rarely practiced in declined slowly between 1990 and 2015.9 This
observed delivery scenarios, regardless of the was largely because of the widespread, outdated,
hospital protocol. and harmful health care provider practices.11
One recently published UNICEF reviews Through collaborative efforts with WHO and
identified problems and bottlenecks in the health UNICEF, it is clear that countries in the region
system to provide newborn care.20 Our research share many similar problems and barriers when
results support these findings and identified more scaling up EENC interventions. The results of this
specific barriers that health workers face introduc- study may help countries working to ensure
ing and practicing EENC in their facilities. First, evidence-based policies and practices are used to
there is no detailed national clinical practice improve their quality of skilled childbirth care.
guidelines for the management of routine deliv-
ery, childbirth, and immediate newborn care. As CONCLUSION
a result, policies and practices within and across
China has been working closely with various
hospitals were often not consistent. The knowl-
partners to prioritize newborn health by devel-
edge on textbooks and experiences from other
oping a national action plan and technical guide-
health workers were often outdated and harmful,
line that aligns with WHO recommendations.
and preservice and in-service trainings usually did
However, at the moment, hospital policies,
not include sufficient instruction on quality EENC.
protocols, and interventions only partially align
The development
As a result, many health workers were unaware
with WHO recommendations. To make EENC
that simple steps could protect newborn infants.
and adoption of easier and safer for hospital workers to practice,
Second, the protocols used must have legal valid-
national expert working groups and national policies
ity for medical disputes and malpractice cases.
evidence-based must be established to address inconsistencies
The development and adoption of national
guidelines must and cultural beliefs and provide a strong,
evidence-based guidelines must therefore be
be initiated and evidence-based set of guidelines for hospitals
initiated and approved by academic authorities or
approved at the and health workers to follow.
at the NHFPC level before being implemented in
national level hospitals and incorporated into an effective ac-
before being Funding: The research was funded by WHO/WPRO.
creditation mechanism. Third, the documents
implemented in used for the evidence base should be made
hospitals and available to all stakeholders, including health Competing Interests: None declared.
incorporated into workers and families of newborns. New practices
an effective need to be supported by an evidence base to
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Peer Reviewed

Received: January 5, 2018; Accepted: April 26, 2018

Cite this article as: Xu T, Yue Q, Wang Y, Murray J, Sobel H. Childbirth and early newborn care practices in 4 provinces in China: a comparison with
WHO recommendations. Glob Health Sci Pract. 2018;6(3):565-573. https://doi.org/10.9745/GHSP-D-18-00017

© Xu et al. This is an open-access article distributed under the terms of the Creative Commons Attribution 4.0 International License (CC BY 4.0), which
permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. To view a copy of
the license, visit http://creativecommons.org/licenses/by/4.0/. When linking to this article, please use the following permanent link: https://doi.org/
10.9745/GHSP-D-18-00017

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