Dear Secretary Duque:

We hope that this letter finds you and your team in good health despite the massive challenges we have been facing. 

It is understandable that this time brings about so much confusion, especially in our medical protocols, as this is a situation that none of us have ever encountered before. And understandably, to prevent the further spread of SARS-Cov-2 virus, the medical field tends to err on the side of caution. We would like to request, however, that the clinical approach to the management of COVID-19 in Pregnancy and the Newborn adopted under Department of Health Memorandum No. 2020-0146 (the “Clinical Approach under DM No. 2020-0146”) be reviewed, especially with regard to the separation of the newborn from the mother. 

While it is understandable that social distancing and isolation must be practiced to slow the spread of the disease, this should not be made to apply to mothers and their newborn babies. A baby should not be treated as an ordinary adult individual as a baby is highly dependent on the mother especially in the first few months of life. For this reason, we have the Unang Yakap or Essential Intrapartum and Newborn Care (“EINC”) protocol. The World Health Organization (“WHO”),  the United Nations Children’s Fund, the United Nations Population Fund, and the World Food Programme recently issued a statement stating that “the most effective way to save newborn lives is still through the practice of EINC”.

We also understand that while China has recommended the blanket approach of separating the mother and the baby, other countries have recommended otherwise:

• The US Center for Disease Control states that the determination of whether or not to separate a mother with known or suspected COVID-19 and her infant should be made on a case to case basis “using shared decision-making between the mother and the clinical team.” Its pregnancy and breastfeeding guidelines also gives even a sick mother the option to directly breastfeed her child provided that she wears a mask and washes her hands before each feeding.
• The American College of Obstetricians and Gynecologists notes that there are only “rare exceptions when breastfeeding or feeding expressed breastmilk is not recommended.”
• The Italian Society on Neonatology (SIN) has taken the position that:
  - If a mother previously identified as COVID-19 positive or under investigation for COVID-19 is asymptomatic or paucisymptomatic at delivery, rooming-in is feasible and direct breastfeeding is advisable, under strict measures of infection control. 
  - On the contrary, when a mother with COVID-19 is too sick to care for the newborn, the neonate will be managed separately and fed fresh expressed breast milk, with no need to pasteurize it, as human milk is not believed to be a vehicle of COVID-19. 
• In Canada’s Alberta Health Services Neonatal Management for 2019 Novel Coronavirus Infection:
  - If the baby asymptomatic and the mother is able to care for the baby, the mother is allowed to breastfeed her child. The  mother is required to wear a mask during breastfeeding and should follow hand and breast hygiene.
  - If the mother is confirmed or suspected with COVID-19, skin-to-skin can be done once the mother is able to do hand hygiene, don mask, and has abdomen/chest wash and the baby is deemed stable.

In its Interim Guiance for clinical management of severe acute respiratory infection (SARI) when COVID-19 disease is suspected dated 13 March 2020, the WHO notes that “breastfeeding protects against morbidity and death in the post-neonatal period and throughout infancy and childhood. The protective effect is particularly strong against infectious diseases that are prevented through both direct transfer of antibodies and other anti-infective factors and long-lasting transfer of immunological competence and memory.” It adds that breastfeeding “should be initiated within 1 hour of birth. Exclusive breastfeeding should continue for 6 months with timely introduction of adequate, safe and properly fed complementary foods at age 6 months, while continuing breastfeeding up to 2 years of age or beyond.” Symptomatic mothers are required to practice respiratory hygiene (wear a mask), perform hand hygiene before and after practicing skin-to-skin contact or breastfeeding their child.

The Philippines has been lauded as having one of the most mother-baby friendly set-ups in the hospital setting. We have come a long way from the routine separation of mothers from their children, and this practice has brought about marked improvements in breastfeeding rates and overall maternal and child health. This pandemic is no reason to stop this practice all of a sudden, except for the most pressing cases. 

Direct breastfeeding has been proven time and again to provide infants with much-needed protection, especially in times like this, as the mother’s body has the unique capability of producing antibodies to viral threats that she has been exposed to. Direct breastfeeding is so important for babies that even if the mother may display mild to moderate symptoms, the WHO and other public health and clinical experts recommend that for as long as mothers practice proper respiratory hygiene (proper handwashing, sanitizing of areas and surfaces the mother has come into contact with, wearing a mask, etc), breastfeeding should be encouraged and supported. And when the mother is weak and unable to breastfeed her baby directly, then she must be given proper guidance and help to express her milk.       We urge you to listen to the UN Agencies, the WHO, the World Food Programme and other public health and clinical experts, to  review the “Clinical Approach under DM No. 2020-0146” and to avoid unnecessary illness and death by ensuring that EINC and breastfeeding are not sacrificed while preventing the spread of infection.