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Bridging traditional and modern maternal care
by Roland Eric Macanas

Progress reports with how the Philippines is faring in terms of complying with Goal 5 of the Millennium Development Goals (MDGs) do not show a rosy picture of the country’s state in terms of reducing by three quarters maternal mortality and complications associated with childbirth by 2015.

At the regional level, the Department of Health said it is struggling to meet the goal of curbing maternal deaths among Cordillerans.

Beliefs that contribute to mortality

Despite innovations in delivery, the DOH said culture and poverty are among the reasons women do not get the medical attention they need while pregnant and after giving birth.

In isolated areas, many rely on traditional and alternative health care. Previous researches also point to customary practices as one reason why during childbirth, only their husbands or traditional midwife (hilot) attends to them.

According to Verderese (1975), “It is customary to place the woman in a kneeling or squatting or lying position at the time of childbirth because it is essentially important to keep the woman’s sense of modesty than modern obstetrical position. The care of the mother may include adjustment of a binder around her abdomen because if she is not well-bound, the uterus may float free of its proper position. She is also discouraged to carry heavy things to prevent the still weak womb from sinking.”

Verderese added if the woman has experienced an irregular open wound caused during childbirth, otherwise known as laceration, salves or herbal concoctions are applied to hasten the healing process. Moreover, Palaganas (2001) learned from a certain manang Maxilinda that a woman who is about to give birth do not lie on her back but will squat or kneel while holding on to a suspended horizontal wood and make full use of gravity to facilitate the delivery of the baby.

While no study claimed these practices are unacceptable and harmful, uncertainty still arises on the possibility of emergency complications that could happen during childbirth that only trained professional health care providers such as doctors, nurses, or midwives can appropriately and timely perform and should be done in an equipped health facility such as hospital or rural health unit (RHU) or barangay health station-birthing center or lying-in clinic where all needed medicines, supplies, and equipment are available.

Complications include severe bleeding, infection, hypertensive disorder, and incomplete extraction of placenta, or the woman might have pre-existing diseases like diabetes.

Responses

The DOH and the Regional Social Development Council led the MDG catch-up planning where all health workers and planning officers in the region were invited to discuss what had to be done.

The DOH has retrained and retooled doctors, nurses, and midwives on obstetric care; and through the Health Facility Enhancement Program, allotted funds for the construction of hospitals, rural health units, and barangay health stations-birthing centers.

DOH Regional Director Valeriano Lopez said the project is carried out within the context of responding to the long-standing concern on bringing holistic health care services to indigenous peoples – one that is culture-sensitive and responsive to the situation unique in a certain locality. It aims to strengthen the local health system in the region to effectively and efficiently deliver maternal and newborn care services.

Lopez added the project is specifically designed to attain the following outputs: 1. Health governance and financing are strengthened through functional Inter-Local Health Zones in target sites; 2. Service deliver framework for maternal and child health is strengthened in target sites; 3. Hospitals, RHUs, and Barangay Health Stations (BHS) become Basic Emergency Obstetric and Newborn Care (BEmONC)-certified by DOH and RHUs and BHSs become Maternal Care Package (MCP) accredited by the PhilHealth in target sites; and 4. Lessons learned and good practices of the project are disseminated nationwide.

To complement these, the DOH also teamed up with the Japan International Cooperation Agency for training and provision of equipment needed to hasten childbirth.

Adjusting to culture, individual needs

The DOH, National Commission on Indigenous Peoples, and the JICA, in coordination with local government units, developed a localized maternal, newborn, and child health and nutrition operations manual that incorporated respect for the culture of indigenous peoples, at the same time administering quality obstetric care.

“Together with the provincial government, NCIP and DOH encouraged personnel at all levels of health facilities to deliver services that protect the traditional belief and individuality of their clients, thus, the clients will feel comfortable, like they are just in their home,” JICA Project Chief Adviser Makoto Tobe said of their project in Apayao.

Tobe said the preferred delivery position of choice of a patient is an example of the adjustment done from the usual practice at the health facility where a mother lies on her back with knees bent, positioned above the hips, and spread apart through the use of stirrups, or lithotomy in medical terms.

He said the proposed shift is supported by the study of Gupta (2004) that in any upright position (e.g., kneeling or squatting or lying down position) that the woman will assume at her choice, several benefits will be experienced by the patient, which include less pain during contractions, making it easier for the birth partner (husband or any person preferred by the patient) to massage the patient at the back, in between contractions.

Tobe said lithotomy is the most commonly employed form of delivery because this is the training taught to doctors or midwives and is the conventional reference position in textbook’s description of the mechanisms of vaginal delivery.

The delivery position of choice is also discussed by trainor-doctors during the regular BEmONC training for teams of doctors, nurses, and midwives and harmonized BEmONC training for midwives and nurses.

Dr. Filipina Ramos, BEmONC course director, said the concept was outlined in the training program including emergency management experienced by the patient. It was also detailed in the evaluation for competency of BEmONC training graduates.

Adopting best practices

“Adon ti agan-anak ditoy birthing center manipod idi nangted ti DOH ti na-pintas nga barangay health station ken JICA ti kagawaan nga mausar nu ada aganak,” says Rocel Bangon, a midwife assigned at the Buluam, Apayao birthing center.

Marie, one of the clients, said she preferred giving birth at the Buluan birthing facility as she felt secure knowing there are medical experts who will assist her and her child before, during, and after birth.

Taking the case of Apayao, which has a complex geographical setup and rich cultural conviction, the Field Health Services Information System of the Provincial Health Office recorded 1,231 or 46 percent of the total 2,277 deliveries in 2010 were performed at home. The province also recorded seven mothers who died during childbirth or within 42 days from the date of giving birth because of complications.

The situation prompted Gov. Elias Bulut, Jr. to upscale the effort on saving the lives of the mothers and newborn. Because of their limited resources, assistance was sought from the DOH in early 2011.

The DOH submitted a project proposal to the JICA for a Cordillera-wide strengthening of local health systems for effective and efficient delivery of maternal and child health services and kicked off its implementation in February 2012 and will conclude in February 2017.

Together with Benguet and six municipalities (Villaviciosa, Penarrubia, Pilar, Dolores, Lagangilang, and San Juan) of Abra, Apayao was selected as a target site to receive full support from JICA such as training from the Baguio General Hospital and Medical Center and equipment. Ifugao, Mountain Province, Kalinga, Baguio City and the remaining 21 municipalities of Abra will be covered by the DOH.

Achievements

The Health Facility Enhancement Program has improved access of health services especially among people in remote areas.

A total of 94 health facilities (14 primary hospitals, 19 RHUs, and 61 barangay health stations) in Benguet, Apayao, and the six municipalities of Abra are equipped and available for providing quality birthing services in their localities with 129 doctors, nurses, and midwives trained on regular BEmONC and 124 midwives and nurses on harmonized BEmONC.

All hospitals have also maintained their DOH license and PhilHealth accreditation while 17 RHUs (two in Apayao, five in Abra, and 10 in Benguet) are accredited to PhilHealth-MCP. Eleven barangay health stations in Benguet are already accredited by PhilHealth for MCP. The remaining 50 are in the process of completing their documentary requirements.

The provincial and municipal governments provided funds for medicines and supplies, and even augmentation for infrastructure of their respective birthing facilities and in the process of sustaining budgetary requirements to ensure that these will be available anytime.

Active tracking of pregnant women, education, and promotion on health facility-based delivery including access of services for pre-natal, post-partum, and newborn care: A total of 3,000 community health team (CHT) members and the barangay-based health volunteers were trained by DOH on their roles and functions as health educators and promoters of maternal and child health, including the use of family health diary and project’s developed educational material (flip chart), supplemented with banners that were posted in identified populations in the barangay.

A CHT convention was also conducted to enhance camaraderie between and among the members, determine the situation of the CHT, and advocate for support from the politicians and facility-based delivery.

Increased awareness among pregnant women, their families and policy makers: local legislation in all 26 project site municipalities (six in Abra, seven in Apayao, and 13 in Benguet) were established, either in the form of ordinance, resolution or executive order, reflecting the provision of birthing services, and other maternal and newborn care at the health facility.

Aside from the sponsorship covered by DOH for PhilHealth enrollment to identified indigent families, the project supported promotional activities of PhilHealth in Benguet, Apayao, and Abra for policymakers aimed to increase enrollment of their respective communities as well as on availment of benefits.

Other achievements include institutionalization of maternal death review towards development of an intervention plan aimed to prevent the occurrence of the same situation and implementation of referral system to ensure that full package of maternal and newborn health will be accessed by the patients within the health service delivery network as well as active follow-up of referred patients and sharing of resources like ambulance and personnel.

Specific in Apayao is the significant increase of mothers giving birth in health facilities from 54 percent of the total deliveries in 2010 to 80 percent in 2013.

This indicates more mothers have understood the importance of being cared for by a doctor, nurse, or midwife. As a result, the province was able to reduce the number of mothers who died because of childbirth complication from seven in 2010 to three in 2013.

DOH is also currently expanding initiatives to Kalinga, Ifugao, Mountain Province, Baguio City, and the remaining 21 municipalities of Abra designed to add up the volume of mothers to access quality services in the health facility while protecting the cultural perspective of the clients.

Lopez said, “Using the model currently implemented in Apayao, Benguet, and the six municipalities of Abra, we will make sure DOH’s technical assistance will respond to the diverse needs of our local populace in accordance with the localized guideline of Maternal and Child Health as well as to the Indigenous Peoples Rights Act.”
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