Early essential newborn care: a decade of scaling up quality, life-saving interventions across East Asia and the Pacific (2013–2023)

Abstract

In 2013, WHO partnered with Ministries of Health and development partners in nine countries in Asia and the Pacific to develop, test and scale-up of Early Essential Newborn Care (EENC), a package of simple evidence-based interventions shown to prevent or treat the most important causes of newborn morbidity and mortality, delivered around birth or in the early newborn period. This effort became the largest regional collaboration to improve the quality of newborn care globally. This article discusses the key achievements and progress in the introduction and scale-up of EENC over the past decade, as well as the remaining challenges and future directions. Policy and programme documents, cross-sectional facility assessments and study data show that EENC was widely adopted across nine countries between 2013 and 2023 using a coaching and data-based approach, with sustained and vastly improved quality of care for all newborns including those born preterm, low birth weight and by caesarean section. Implementation replaced ineffective training-based approaches with on-the-job clinical coaching tailored to routine environments. Multidisciplinary hospital teams drove national scale-up and systems improvements by identifying what their facilities and those in their catchment population needed to support practice change. The periodic collection and immediate use of practice data for tracking progress and making programme decisions represented a significant change in how public health programme implementation and scale-up was conducted in the region.

SUMMARY BOX.

• The WHO Western Pacific Regional Office and nine countries in East Asia and the Pacific developed, tested and scaled-up Early Essential Newborn Care (EENC) between 2013 and 2023.

• Sustained and vastly improved quality of care for all newborns including those born preterm, low birth weight and by caesarean section were seen over ten years.

• Previously ineffective training-based approaches were replaced by small group on-the-job clinical coaching tailored to routine environments;

  multidisciplinary hospital teams conducted staff coaching, used local data to improve systems to support quality and drove national scale-up and policy adoption.

• The periodic collection and immediate use of practice data for tracking progress and making programme decisions represented a significant change in how public health programme implementation and scale-up was conducted in the region.

Introduction

Development of scalable evidence-based approaches to improving the quality of newborn care in lower middle-income countries is a global priority.¹ Since 1990, global newborn mortality reduction has lagged that of postneonatal infants and children 1–4 years of age.² In East Asia and the Pacific, an estimated 231 000 newborns died in 2012, about one newborn every 2 min, and newborn deaths accounted for 56% of all under-5 deaths in the region.^{1 3}

To address this challenge, the WHO Western Pacific Regional Office (WPRO) and Member States initiated a strategic shift towards improving the quality of early newborn care. This shift was built on recognition that two-thirds of newborn deaths occur in the first 3 days of life, mainly from complications related to prematurity, birth asphyxia and infection⁴; and that health workers in Asia often used outdated and harmful clinical practices during and after delivery, increasing the risk for newborn morbidity and mortality.⁵,⁷ Further, by 2012, 91.8% of all births in the region were conducted by skilled birth providers, making improving the quality of skilled care a priority.^{8 9}

This effort became the largest regional collaboration to improve the quality of newborn care globally. In this article, we describe key achievements and progress with improving the quality of newborn care over the past decade, the main remaining challenges and future directions.

Background to the introduction of Early Essential Newborn Care in East Asia and the Pacific

In 2013, WHO partnered with Ministries of Health (MoHs) and development partners in Asia and the Pacific to develop the Action Plan for Healthy Newborn Infants in the Western Pacific Region (2014–2020) targeting countries with the highest burden of newborn deaths.¹⁰ The heart of this approach was development, testing and scale-up of Early Essential Newborn Care (EENC), a package of simple evidence-based interventions shown to prevent or treat the most important causes of newborn morbidity and mortality, delivered around birth or in the early newborn period.¹¹ EENC interventions during labour include birth companion, position of choice, food and fluids on demand and elimination of harmful or unnecessary practices such as fundal pressure and enema. In the newborn period interventions include immediate and thorough drying; immediate and sustained skin-to-skin contact (SSC); delayed cord clamping; bag and mask resuscitation for non-breathing babies; timely initiation of early and exclusive breastfeeding when feeding cues are present; appropriately timed hand-hygiene practices and elimination of unnecessary caesarean sections, routine suctioning, episiotomies and admissions to neonatal care units (NCU). EENC also includes Kangaroo Mother Care (KMC), rarely practised, but which can prevent half of deaths of preterm and low birth weight (PTLBW) babies and promote growth and brain development; and use of corticosteroids and magnesium sulfate for mothers in early labour to reduce respiratory and neurological complications.¹²

To institutionalise EENC, WHO partnered with MoHs to develop, test and scale-up EENC coaching, quality improvement assessment and planning tools and indicators to support practice change. The plan initially targeted the eight countries with the highest burden of newborn deaths.¹³ Early development and implementation of EENC was initiated in the Philippines (2010) and Cambodia (2011), before finalisation of the Regional Action Plan and then Mongolia, Vietnam (2014), Lao People’s Democratic Republic (PDR), Solomon Islands, Papua New Guinea, China (2015) and Vanuatu (2019) (figure 1a). Periodic biennial or triennial evaluations of national and subnational health facilities conducted by country programme teams documented progress and supported hospital and national plans to further improve quality.¹⁴ Routine programme data included EENC policies, strategies and plans; the proportion of facilities and staff receiving EENC coaching; and facility practice data from EENC facility assessments conducted between 2015 and 2022 using standard WHO methods and tools and uploaded to the WHO/WPRO EENC country database.¹⁵ An EENC Independent Review Group validated country data.¹⁶,¹⁸ Baseline observations done pre-coaching were used to estimate practices in 2011. Facility assessments included randomly sampled national, provincial and district hospitals; and first-level facilities with that had introduced EENC. Standard checklists were used for interviewing mothers, observing births, reviewing maternal-newborn charts, hospital policies and environments and validating records.¹⁴ Births on the day of the visit were observed in sampled facilities using a standard checklist of 24 sequential practice steps required to deliver maternal and newborn interventions around childbirth.¹⁴ Regional progress meetings were convened to exchange experience, motivate, discuss common problems encountered during implementation and develop data-driven biennial country roadmaps to accelerate scale-up.

Figure 1. (a) Early Essential Newborn Care (EENC) implementing countries by year of implementation. (b) Health facility staff coached in EENC, by country, 2010–2023. Source: estimated total number of health staff (hospitals and primary care facilities) coached in EENC from country programme reports, 2010–2023.¹⁸ (c) Health facilities providing childbirth services that have introduced EENC (%), by country, 2015–2023. Source: proportion of estimated total number of facilities providing birth services (hospitals and primary care facilities) introducing EENC from country programme reports 2015–2023.¹⁸ CHN, China; KHM, Cambodia; LAO, Lao People’s Democratic Republic; MNG, Mongolia; PHL, Philippines; PNG, Papua New Guinea; SLB, Solomon Islands; VNM, Vietnam; VUT, Vanuatu.

Key achievements

Widespread country coverage of EENC clinical coaching

Implementation of EENC involved coaching health facility staff on appropriate childbirth and immediate newborn care practices using adult learning methodologies, focusing on delivery room practices.¹⁹ Coaching for management of breathing and non-breathing babies was developed and then improved using repeated test-revise cycles across different facility and country settings to optimise feasibility, accuracy and practicality of the method. The final protocol included 21 sequential time-bound steps for the breathing baby and 30 for the non-breathing baby from delivery preparation until the immediate newborn period. Coaching was conducted in delivery rooms using a practice-based approach with newborn mannikins, no lectures or presentations and limited reading. Staff selected for coaching included midwives, nurses, obstetricians, neonatologists, paediatricians, managers, infection prevention and control staff and others involved in delivery and immediate newborn care. A facilitator to participant ratio of 1:6 was used to allow repeated practice and feedback for all participants. This approach improved understanding of evidence-based practices and how they can be applied and sequenced in routine work environments. Importantly, it facilitated communication between paediatric, neonatal and obstetrics staff who rarely communicated on newborn care pre-EENC. Clinical coaching represented a departure from previous didactic training-based methods and was demonstrated to result in sustained skills retention.^{13 20} Initially used for term babies born vaginally, EENC was progressively expanded to include stable preterm and caesarean births. By 2023, at least 6446 facilities with 42 403 staff had been coached on EENC across nine countries. Five countries had achieved the regional target of 80% of childbirth facilities implementing EENC, and an additional three countries were on track (figure 1b and c).¹⁷

Multidisciplinary team-based approach for establishing quality improvement

Multidisciplinary EENC hospital teams were the foundation of implementation and scale-up. Initially focusing on coaching of delivery staff, teams were subsequently trained in a quality improvement approach using periodic observations of routine childbirth and newborn care at the hospital.²¹ Data were immediately summarised and used to identify practices requiring improvement and corresponding actions to improve care. Hospital facilitators coached operating theatre teams to apply the approach for operative births under both regional and general anaesthesia.^{22 23} Hospital teams were responsible for coaching facility staff in their catchment area and addressing barriers to adoption. These included revising birth practice guidelines, reorganising workspaces, redefining health worker roles, resequencing of tasks around birth, ensuring availability of basic resuscitation equipment, drying cloths and baby hats and improving communication with mothers and families. Changes in hospital policies and protocols focused on reducing unnecessary newborn separations and other harmful practices and increasing breastfeeding. The latter required expanding the required duration of uninterrupted SSC to at least 90 minutes, promoting rooming-in and enforcing the Code on Marketing of Breastmilk Substitutes. Code enforcement in facilities varied by country but generally focused on improving breastfeeding support along the care pathway (improved counselling around birth, lactation support), creating supportive environments (rooming-in, removing bottles and formula from postnatal wards and eliminating sales of formula from vendors either within or just outside facilities and improved communication (print materials, posters and antenatal and postnatal counselling of women, fathers and grandparents). Industry-supported materials were prohibited. Staff often had grown accustomed to formula being brought into facilities and tolerated its use. They needed clear guidance to ensure that this was no longer allowed; and to counsel family members, who were often responsible for introducing bottles and formula after birth. Ultimately, hospital experience informed national and subnational policies, protocols and planning. By 2023, of 157 EENC-implementing hospitals surveyed across the region, 75% had an EENC hospital team supported by senior management.

Programme policies and systems to support introduction and scale-up

Establishing programme readiness benchmarks helped develop and sustain country introduction and adoption of EENC. By 2023, all reporting countries had appointed full-time MoH EENC focal persons, conducted EENC facility implementation reviews within 2 years, adopted the Early Essential Newborn Care: Clinical Practice Pocket Guide²³ and incorporated EENC standards into preservice curricula. Eighty-six per cent reported having conducted a newborn health situation analysis within the past 5 years, developed costed 5-year EENC implementation plans and established alliances with professional associations. Fifty-seven per cent had functional EENC Technical Working Groups that met regularly to develop guidelines, review progress, plan country actions and engage broader stakeholder groups (figure 2). Integrating updated newborn care policies into national maternal and child health strategic plans, fast-track initiatives and targeted directives enabled EENC to be included in national and subnational planning, budgeting and annual reviews. Rates of scale-up implementation varied between countries, depending on the approach taken. China, with the largest number of facilities, chose to begin in four provinces and prioritise implementation research to investigate feasibility and effectiveness of EENC in the Chinese context before expanding more widely.²⁴ Periodic regional data reviews enabled countries to work towards a common vision, learn from each other about how critical problems were overcome and develop and commit to country action roadmaps.²⁵

Figure 2. Priority countries achieving Early Essential Newborn Care (EENC) scale-up readiness benchmarks (%), 2015–2023. Source: proportion of estimated total number of facilities providing birth services (hospitals and primary care facilities) introducing EENC from country programme reports 2015–2023.¹⁸ TWG, Technical Working Group.

Improvements in early newborn care birth practices

Pre-EENC evidence-based practices were rarely applied. A low proportion of term babies were observed to receive drying and SSC in Cambodia, the Philippines and Vietnam, while unnecessary separation for ‘observation’ was universal^{5 26 27} (table 1). By 2023, most key practice measures were significantly improved from the pre-EENC period, including early drying (77.1%), thorough drying (70.2%), any SSC (92.7%), SSC within 1 min of birth (73.3%), SSC ≥60 min (59.0%), SSC ≥90 min (47.1%) and delayed cord clamping (89.9%) (table 1). Overall, 70.2% of newborns received early breastfeeding (within 15–90 min of birth), 64.4% with uninterrupted SSC with the mother and 69.8% exclusively breastfed on discharge (the median time of maternal interview was 36 hours (IQR 18–71) after birth). No babies received routine suctioning in 2023, 7.8% had substances placed on the cord stump and 17.8% of newborns received early bathing. The average observed clinical practice birth score rose to 91% of the maximum score for breathing babies by 2023.

Table 1. Newborn care practices at birth from facility assessments conducted in Asia and the Pacific, nine countries, 2008–2020.

Key practice	Pre-EENC*		Post-EENC*
	Philippines hospital study 2008 % (n)5 (N=454)	Cambodia and Vietnam practice reviews 2011/14%(n)26 27 (N=43)	Eight countries practice reviews 2017% (n) (N=1412/368)†	Nine countries practice reviews 2020% (n) (N=1952/494)‡	Seven countries practice reviews 2023% (n) (N=1581/476)§
Beneficial practices
Any drying	97.4 (442)	–	100.0 (368)	100.0 (494)	100.0 (476)
Dried within 5 s of birth	2.2 (10)	0.0 (0/43)	83.2 (306)	91.7 (453)	77.1 (367)
Thorough drying	–	0.0 (0/43)	84.0 (309)	90.7 (448)	70.2 (334)
Any skin-to-skin contact initiated at birth	9.5 (43)	0.0 (0/43)	86.9 (1227)	91.1 (1778)	92.7 (1466)
Immediate skin-to-skin contact (<1 min)	1.1 (5)	0.0 (0/43)	74.3 (1049)	72.1 (1408)	73.3 (1159)
Uninterrupted skin-to-skin contact for at least 60 min	0.0 (0)	0.0 (0/43)	46.8 (661)	46.8 (913)	59.0 (834)
Uninterrupted skin-to-skin contact for at least 90 min	0.0 (0)	0.0 (0/43)	36.2 (511)	37.0 (723)	47.2 (746)
Delayed cord-clamping (1–3 min) Median time	1.3 (8) 12 s	2.3 (1/43) –	89.7 (330) –	93.7 (458) –	89.8 (460)
Any breastfeeding after birth	68.9 (313)	–	95.0 (1341)	95.9 (1872)	95.3 (1506)
Breastfeeding initiated in the first 90 min	51.3 (233)	–	76.6 (1083)	76.2 (1488)	–
Breastfeeding initiated 15–90 min	16.3 (74)	–	61.5 (868)	57.3 (1118)	70.2 (1110)
Breastfeeding initiated without separation	1.1 (5)	–	56.1 (792)	56.0 (1093)	64.4 (1018)
Breastfeed duration at least 15 min Median time Median duration	6.4 (29) 3 min	– –	52.2 (737)	53.8 (1051)	59.3 (938)
Breastfeeding initiated 15–90 min, duration ≥15 min	2.9 (13)	–	34.4 (486)	33.4 (652)	45.8 (724)
Harmful practices
Routine suctioning	94.9 (432)	–	0.3 (1/371)	0.0 (494)	0.00 (460)
Early bathing Median time	89.9 (408) 8 min	–	27.3 (193/708)	35.7 (314/880)	17.8 (183/1029)
Substances on the cord stump	99.3 (451)	–	10.6 (150)	11.5 (224)	7.8 (124)
Average EENC clinical practice score (% maximum)¶	–	–	83.3 (333)	88.1 (491)	91.0% (476)

^*Babies not breathing spontaneously at birth are excluded from all analyses.

^†A total of 161 health facilities implementing EENC sampled across eight countries (32 national/regional and 121 first-level referral hospitals and eight first-level facilities). At sampled facilities, 1412 maternal postpartum interviews and 368 delivery observations of term babies were conducted.^{15 16}

^‡A total of 216 health facilities implementing EENC were sampled across nine countries: 49 national/regional and 136 first-level referral hospitals and 31 first-level facilities. At sampled facilities, 1952 maternal postpartum interviews and 494 delivery observations of term babies were conducted.^{15 17}

^§A total of 207 health facilities implementing EENC were sampled across seven countries: 29 national/regional and 72 first-level referral hospitals and 106 first-level facilities. At sampled facilities, 1581 maternal postpartum interviews and 512 delivery observations of term babies were conducted.^{15 18}

^¶The standard birth observation checklist for breathing babies includes 21 time-bound sequential practice steps required to deliver effective maternal and newborn interventions around childbirth. At observation, performance of each practice is scored as yes (2 points), partial (1 point) and no (0 points), with a maximum possible score of 42.¹⁹

EENC, Early Essential Newborn Care.

Despite the benefits of EENC for babies born PTLBW or by caesarean section, these highly vulnerable newborns continued to be admitted to NCU, often formula fed, unnecessarily handled and bathed, exposing them to hospital bacteria, hypothermia and consequent complications.²⁸ From 2017, this led to an increased focus on targeting PTLBW newborn care practices including revision of NCU admission policies to ensure that only newborns requiring specialised care or monitoring were admitted and reorganising operating theatres to enable SSC post-caesarean section.²⁹ Babies born vaginally continue to be more likely to receive core practices. However, dramatic improvements are noted for caesarean births. By 2023, 71.7% of all babies born by caesarean section received SSC, 41% for at least 60 min and 26.9% for 90 min; 54.5% breastfed 15–90 min after birth and 70.6% breastfed exclusively at discharge (figure 3).

Figure 3. (a) Skin-to-skin and breastfeeding practices for newborns born term and preterm low birth weight, seven countries, 2023. (b) Skin-to-skin and breastfeeding practices for newborns born vaginally and by caesarean section, seven countries, 2023. Source: 2023: interviews with 1808 postnatal mothers in 207 health facilities implementing Early Essential Newborn Care (29 national/regional, 72 first-level referral and 106 first-level facilities). No facility assessment data available from the Philippines and Vanuatu.^{15 18} SSC, skin-to-skin contact.

By 2023, 69.2% of PTLBW newborns received SSC, 48.9% within 1 min of birth and 23.8% uninterrupted for 90 min; 36.6% breastfed 15–90 min after birth, 74.9% breastfed exclusively at discharge and 12.5% were given non-recommended bottle feeds. For women 24–34 weeks’ gestation meeting criteria for antenatal corticosteroid use (to improve lung function), 54.8% received them in 2023; with 37.3% of women under 32 weeks’ gestation receiving magnesium sulfate (for fetal neuroprotection). Fifty-six per cent of PTLBW babies (≤2000 g) received any KMC in 2023, compared with 7% in 2015, with 40.0% receiving continuous KMC for at least 20 of the previous 24 hours.^{15 18}

Delivery at scale and newborn health impact

Country implementation studies augmented programme data by showing that EENC delivered at scale using a coaching-based systems strengthening approach improved SCC, breastfeeding and other key practices²⁰³⁰,³²; uptake of KMC³³ and exclusive breastfeeding for PTLBW newborns.³⁴ Delivery of EENC has been associated with reductions in unnecessary NCU admissions, hypothermia, sepsis and improved maternal outcomes including reduced duration of the third stage of labour and postpartum blood loss for both vaginal and caesarean births.²⁹³⁵,³⁷ The most recent population-based coverage data found that 76.8% of Cambodian newborns received SCC (2020/2021), 71% in the Philippines (2023, rising from 8% in 2008), 79.4% in Mongolia (2023), 43% in Papua New Guinea (2016/2018) and 13.7% in Lao PDR (declining from 17% in 2017).^{18 25} Thus, improved facility-based EENC practices are reaching an increasing proportion of births in most implementation countries, except for Lao PDR.

Redefined practice indicators to reflect practice realities

Prior to EENC, WHO recommended SSC in the first hour after birth but did not specify when SSC should begin or how long it should be sustained. SSC was often delayed, interrupted for unnecessary routine tasks and continued for brief periods (table 1). Cross-regional data from eight EENC implementing countries and study data from China and Vietnam found a strong dose-response relationship between duration of SSC and early breastfeeding initiation and exclusive breastfeeding at discharge through 90 min after birth, regardless of the mode of delivery.^{36 38 39} These findings are consistent with physiological data showing that readiness to breastfeed is highly variable between newborns, with the median time of first breastfeed around 55 min postpartum.⁴⁰ Early (<1 min) and uninterrupted SSC for at least 90 min were subsequently adopted as key practice indicators.

Pre-EENC, babies were routinely forced on the breast before feeding cues which health workers rarely recognised; and removed before the baby had a chance to ingest colostrum. The global indicator for breastfeeding initiation within the first hour creates confusion for health workers. EENC emphasises supporting breastfeeding when feeding cues appear (usually 15–90 min) to counter this confusion. Adding breastfeeding of at least 15 min duration aimed to reinforce this principle and to eliminate early removal from the breast before an adequate feed had taken place.

Remaining challenges

Despite major improvements, some birth practices declined or stalled as they became routine (eg, thorough drying, immediate SSC <1 min), with less attention paid to their primary purpose. This was particularly true as new staff with less practical experience entered birthing areas. It remains critical that regular practice observations with feedback are incorporated into facility routines to support continued application of standards. Practice gaps remain for babies born PTLBW or by caesarean section. Continuous KMC remains suboptimal.⁷ Early and unnecessary mother-baby separations are often attributed to availability of space, staff time limitations, concerns about privacy, family fears and resistance by senior staff.^{25 30} Reasons postulated for why SSC and early newborn care practices are not performed at caesarean section births include fears that it will compromise the sterile field, concerns for the safety of mothers and babies, perceived additional work, physical organisation of the operating room and poor coordination and communication between anaesthesiology and obstetrics staff. These concerns often persist despite evidence that it is feasible, effective and well-accepted by mothers.^{41 42}

Ensuring early and exclusive breastfeeding needs continued attention for all newborns. Significant improvements in exclusive breastfeeding practices for PTLBW newborns reflect widespread adoption of non-separation policies and NCU non-admission policies for well babies born both vaginally and by caesarean section. Most PTLBW newborns are moderate to late (32–36 weeks), with a large proportion capable of breastfeeding. Average early and exclusive breastfeeding rates for the larger numbers of stable term babies remain around 70%, a significant improvement from the pre-EENC period. EENC implementation includes Baby Friendly Hospital Initiative (BFHI) clinical practice steps (3–10).^{14 43} Ensuring support for Code practices and maintaining staff skills (BFHI steps 1–2) remains challenging. Regional data show that having formula company promotional products and materials present in facilities is associated with significant reductions in exclusive breastfeeding, while having a written, posted policy prohibiting formula company products has significantly higher rates.³⁹ Implementation remains highly variable within and between countries.

Gaps in handwashing resources in birth and postnatal areas remain common across the region and need more directed attention.⁴⁴ Although most countries have begun incorporating EENC standards and coaching methods into preservice curricula, the quality and extent of it remains uncertain. Preservice curriculum reviews and updates are difficult because of the numerous preservice educational institutions and the time and coordination required for systematic curriculum reviews. This common problem needs more attention, including development of new tools for quantifying competency gaps.⁴⁵

Better quality data are needed on newborn resuscitation practices and newborn sepsis management, since these cases are rarely observed during periodic assessments. Valid and reliable hospital outcome and impact data have not been collected through routine data systems except in Mongolia, which integrated newborn indicators into routine maternal and child health facility surveillance. Common problems with facility data collection systems include incomplete recording and reporting, particularly for birth weight and gestational age, and incorrectly or inconsistently applied indicator definitions for newborn mortality, prematurity, birth asphyxia and sepsis.²⁵ Ensuring large sample population-based surveys measure SSC and other birth practices is essential for tracking coverage and identifying inequities so that EENC can be targeted to vulnerable populations.⁴⁶

The next decade

In the next decade, scale-up of EENC will continue, most notably in China, which has the lowest regional coverage, but which has embarked on an ambitious plan to test and document effectiveness before scaling-up. It is now poised to expand to 31 provinces by 2025.²⁴ Efforts to improve duration of uninterrupted SSC for at least 90 min for all newborns, especially for stable babies born PTLBW or by caesarean section should be expanded, with more emphasis on continuous KMC for all eligible PTLBW babies. Local quality improvement approaches will need to be augmented to include health worker and facility licensing and accreditation; and other policy, protocol and environmental changes needed to support effective practices for high-risk newborns. Given external corporate threats to breastfeeding in Asia, ensuring that key BFHI strategies are reinforced and applied consistently will continue to be emphasised, with increased attention to monitoring and enforcing the Code of marketing of breastmilk substitutes.⁴⁷ Elimination of bottles and formula advertising and sales in and around facilities, and ensuring they are not introduced by mothers and families or tolerated by staff will need sustained effort. More attention will be given to improving the quality of preservice training to ensure both evidence-based content and practice-based methods are incorporated; and national training competencies are updated. Strengthening routine collection and use of newborn outcome data remains a priority as does better incorporation of EENC indicators into routine coverage surveys. Since EENC was primarily implemented through existing government systems with local resources, detailed cost-effectiveness analyses are warranted to quantify relative cost-effectiveness of implementation in different practice settings. Furthermore, mortality attribution analyses will quantify expected deaths averted following improved application of evidence-based practices on a large scale following EENC scale-up.⁴⁸

Conclusions

EENC has been widely adopted across East Asia and the Pacific using a coaching and data-based approach and is associated with sustained and vastly improved quality of care. Hospital teams remain fundamental to introduction, driving national scale-up and policy adoption by identifying what their facilities and those in their catchment population need to support practice change. The periodic collection and immediate use of practice data for tracking progress and making programme decisions represented a significant change in how public health programme implementation and scale-up was conducted in the region.

The author is a staff member of the World Health Organization. The author alone is responsible for the views expressed in this publication and they do not necessarily represent the views, decisions or policies of the World Health Organization.

The authors alone are responsible for the views expressed in this article, which do not necessarily represent the views, decisions or policies of the institutions with which they are affiliated.

Data availability statement

Data are available on reasonable request.