Philippine Government Policies in Reducing Maternal Mortality

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health (RH) services by women, including poor adolescents and men. Most maternal death and disability could be averted if:

- all pregnancies were wanted,- all births were attended by skilled health

professionals and- all complications were managed in quality

referral facilities offering emergency obstetric care.4

This policy brief is intended to give guidance to policy-makers and others engaged in planning and implementing policies and programs in maternal health in the Philippines with recommendations that might be useful in reviewing and assessing the country’s maternal health care policies and programs. The analysis is based on a review of literature, policy documents, tools, and other relevant materials to bring together up-to-date evidence from a variety of sources. Moreover, a focus group discussion was conducted with selected key informants among officers and members of the Integrated Midwives Association of the Philippines (IMAP) who are closely involved with safe motherhood/maternal health programs of the country for many years.

Since the late 1980s, improving maternal health and reducing maternal mortality have been key concerns of several international summits and conferences, including the Millennium Summit in 2000.1 One of the eight Millennium Development Goals (MDGs) adopted following the Millennium Summit involves improving maternal health (MDG5). Within the MDG monitoring framework, the international community committed itself to reducing the maternal mortality ratio (MMR), and set a target of a decline of three quarters between 1990 and 2015. Thus, the MMR is a key indicator for monitoring progress towards the achievement of MDG5.

In the Philippines, eleven women die every 24 hours from almost entirely preventable causes related to pregnancy and childbirth.2 Maternal mortality ratio (MMR) continues to be staggeringly high, at 162 maternal deaths for every 100,000 live births3 compared with 110 in Thailand, 62 in Malaysia, and 14 in Singapore.

Universal access to sexual and reproductive health education, information, and services improves health, saves lives and reduces poverty. The slow decline in MMR in the country may be traced to inadequate access to integrated reproductive

OverviewBy Carlos O. Tulali

Maternal MortalityPhilippine Government Policies in Reducing

2 PLCPD POLICY BRIEF | Philippine Government Policies in Reducing Maternal Mortality

Maternal Health Situation

Results of the 2008 National Demographic and Health Survey (NDHS) indicate that about 91 percent of Filipino women with at least one live birth in the 5 years prior to the 2008 NDHS had received antenatal care from a health professional compared to 88 percent of the women based on the 2003 NDHS (Table 1). Among all births in the 5 years preceding the 2008 NDHS, 62 percent were delivered by a health professional compared to 60 percent reported in the 2003 NDHS.7 While this represents adequate coverage, there is marked difference in access across regions and income groups.

Based on the 2008 NDHS results, the contraceptive prevalence rate (CPR) of the Philippines is only 50.7 percent (Table 2). This means that only a little more than half of married Filipino women use FP methods, whether traditional (16.7 percent) or modern (34 percent). Only 0.4 percent use “other traditional method” (natural family planning).

Table 1. Selected maternal care indicators, Philippines: 2003 and 2008 NDHS

Indicators 2003 2008Percentage of women age 15-49 with one or more live births in the 5 years before the survey who received antenatal care for the youngest child from a health professional

87.6 91.0

Percentage delivered by a health professional among all births in the 5 years before the survey

59.8 61.8

Percentage delivered in a health facility among all births in the 5 years before the survey

37.9 43.8

Sources: 2003 and 2008 National Demographic and Health Surveys

Table 2. Percent distribution of currently married women by contraceptive method used, Philippines: 2003, 2008

Method 2003 2008Any method 48.9 50.7Any modern method 33.4 34.0Any traditional method 15.5 16.7Not currently using 51.1 49.3Total 100.0 100.0Sources: 2003 and 2008 National Demographic and Health Surveys

3PLCPD POLICY BRIEF | Philippine Government Policies in Reducing Maternal Mortality

This situation leads to more pregnancies and deliveries among Filipino women. And yet, an overwhelming majority of Filipinos (92%) believe that it is important to manage fertility and plan their family, and most (89 percent) say that the government should provide budgetary support for modern artificial methods of FP, including the pill, intra-uterine devices (IUDs), condoms, ligation, and vasectomy, based on a 2007 survey on FP in the Philippines conducted by Pulse Asia.8 In another survey, the majority (55%) of respondents said that they are willing to pay for the FP method of their choice.9

These survey results prove that Filipino women lack RH care, including information on, and access to, FP methods of their choice. Births that are too frequent and spaced too closely take a debilitating toll on their health, so that many of them die during pregnancy or at childbirth. Some of them, despairing over yet another pregnancy, seek an abortion, from which they also die and along with them, their unborn child. Based on another study conducted by the Allan Guttmacher Institute in 2006, of the three million annual pregnancies in the country, half were unplanned and one-third of these end in abortions.10

Causes and prevention of maternal deaths

The Philippine government’s MDG progress report states that 1 in 100 women die as a result of “maternal causes,” and that maternal deaths accounted for about 14 percent of all deaths among women of reproductive age (15–49).11 The underlying causes for the situation are: (1) inadequate capacity of the health/medical facility to provide quality emergency obstetric care (EmOC) services in terms of human resource, skills, equipment, and medicine; and nonfunctional referral system for referring high-risk pregnancies. Lack of awareness on the part of mothers to seek timely medical care and preference of mothers to conduct deliveries at their homes are also contributing factors.

As revealed by the State of Filipino Mothers 2008 report by Save the Children, not only do Filipino mothers die because of biomedical causes

and risk factors, they also lack access to both lifesaving care and quality maternal/reproductive health care.12 According to the report, these are the reasons why Filipino mothers die:

1. limited access to health facilities and quality maternal care;

2. lack of access to a full-range of reproductive health care, including family planning information and services;

3. unplanned pregnancies leading to induced abortion, and consequently, maternal deaths;

4. lack of political will to provide maternal health services;

5. lack of a reproductive health law that would require appropriate funds to ensure full access to quality RH information and services that include maternal health and family planning.

The dangers of childbearing can be greatly reduced if a woman is healthy and well-nourished before becoming pregnant, if she has a health checkup by a trained health worker during her pregnancy, and if a skilled birth attendant assists the birth. The woman should also be checked during the 12 hours after delivery until six weeks after giving birth. The government has a particular responsibility to make prenatal and postnatal services available, to train health workers to assists at birth, and to provide special care and referral services for women who have serious problems during pregnancy and childbirth.

Unmet need and short birth intervals

Research from developing countries revealed that unhealthy timing or spacing of pregnancies is linked to increased risk of multiple adverse health outcomes.13 14 Following a pregnancy that occurred quickly after a previous birth, the risk of a child dying is at least twice as high as that for longer intervals. A recent study of Filipino women’s contraceptive needs revealed that one-third of women at risk did not want to become pregnant within the next two years, while the remaining two-thirds did not want any more children.15 Compared to women who want to end childbearing, women


who wanted to delay a birth were more likely to be using no method and therefore to have an unmet need for contraception. The Philippines has a contraceptive prevalence rate (CPR) of over 50 percent, however, available data and information indicate that the higher risks of short birth intervals and early pregnancies still represent a major RH issue. The problem of short birth intervals is even more pronounced in younger women, among whom the highest risks from very short birth intervals are more common.16 To reduce the current number of pregnancies that occur less than recommended intervals, couples will need easier access to spacing services that are responsive to their circumstances.

MDG and ICPD maternal health targets

The Philippines is a signatory to the UN Millennium Declaration on the global agenda for development by 2015. Consistent with its constitutional mandate of making essential goods, health and other social services available

to all the people at affordable cost, and giving priority to the needs of the underprivileged, sick, elderly, disabled, women and children, the Philippine government has committed to achieve the Millennium Development Goals (MDGs) by 2015. This commitment includes, among others, reducing the maternal mortality ratio (MMR) by 75 percent from 1990 to 2015, along with increasing access to reproductive health (RH) by 2015. The health goals and the strategies to reach these targets are further reiterated in the Medium Term Philippine Development Plan 2004-2010 and the National Objectives for Health 2005-10 (Table 3).

MDG 5 also highlights the crucial role of midwives and others with midwifery skills on the path to improved maternal health by including as its second indicator the proportion of births attended by skilled health providers. Although the percentages are not specified, it is assumed that the target for 2015, “universal access to a skilled birth attendant”, translates into between 90 percent and 100 percent coverage.

Table 3. National Objectives for Health 2005-2010, Philippines

Objectives Indicator Target Baseline Data andSource

Reduce maternalmortality

Maternal mortality ratio per 100,000 live births (MDG Target)

90 maternal deaths per 100,000 live births

172 maternal deaths per 100,000 live births(NDHS 1998)

Reduce perinatalmortality

Perinatal mortality rate per 100,000 live births

18 perinatal deaths per 1000 live births

24 perinatal deaths per 1000 live births(NDHS 2003)

Reduce low birthweight infants

Percentage of low birth weight infants out of total live births

10 percent 12 percent(NDHS 2003)

Reduce risk factorsassociated withmaternal morbidityand mortality

Prevalence rate of iron deficiency anemia among the pregnant

38 percent 43.9 percent (National Nutrition Survey 2003)

Total contraceptive prevalence rate 80 percent 48.9 percent(NDHS 2003)

Percentage of deliveries assisted by skilled birth attendants and in a health facility (MDG Target)

70 percent 53.9 percent(NDHS 2003)

Percentage of postpartumfirst visit within the first week of delivery

80 percent 51 percent(NDHS 2003)

Source; DOH 2007


Of the eight MDGs, the Philippines is said to be on schedule except with Goal 5. The rate of decline in MMR in the Philippines has been quite slow, declining by only about 22 percent in 13 years from 209 per 100,000 live births in 1993 to 162 in 200617. Given this trend, there is little likelihood of the Philippines reaching the 2015 target of 52. In fact, in its Midterm Progress Report on the MDGs, the government has already stated that “goal 5 has been identified as the least likely to be achieved for the Philippines.”18

As a signatory to the ICPD, the Philippines also showed marked deficits with respect to meeting ICPD goals in three specific areas:

- births attended by health professionals;- contraceptive prevalence rate among

women of reproductive age; and - maternal mortality.

Health sector reform

The Philippines’ Department of Health (DOH) initiated the Health Sector Reform Agenda (HSRA) in 1999. Devolution, following the Local Government Code of 1991, had fragmented the health service delivery system as administrative and financial responsibilities have been shared since then among central, provincial, and local authorities, without effective coordination and cooperation mechanisms in place. As a result, public health programs suffered most from an apparent lack of attention. The budget deficit of the national Government and declining public sector resources aggravated the situation. HSRA was introduced to help streamline the health service delivery system with a comprehensive program covering five broad areas of reform:19

1. providing fiscal autonomy to hospitals, 2. securing funding for priority public health

programs, 3. promoting the development of local health

systems and ensuring their effective performance,

4. strengthening capacit ies of health regulatory agencies, and

5. expanding coverage of the national health insurance program.

In summary, HSRA was expected to improve the efficiency of the health service delivery system by integrating health care promotion and prevention, improving referral links, reducing the need for hospitalization, and thereby improving the allocation and use of resources. Such, however, was not the case.

The HSRA objective is to shift the burden of health care costs from household out-of-pocket expenditures to the public sector and to PhilHealth. The coverage of the population is to be expanded, especially to reach the poor (indigents) and the informal sector by providing packages of tailor-made benefits. PhilHealth coverage is still low overall, and very uneven among provinces. Nationwide, only 20 percent of indigents are covered. However, counting the enrolled poor is difficult as poverty data do not exist at municipal levels, and LGUs cannot appropriately map where the poor are. In addition, the current benefits package is limited, and does not provide preventive health care, or basic curative care against catastrophic illnesses.20

In 2005, the Department of Health (DOH) also launched FOURmula ONE (F1) for Health as the new health sector reform implementation framework, through which, critical reforms will be undertaken with “speed, precision, and effective coordination” and are directed at improving the efficiency effectiveness and equity of the Philippine health system. F1 for Health is the implementation framework for health sector reforms in the Philippines for the medium term covering 2005-2010. It is designed to implement


within one hour travel time, operational on a 24-hour basis, and capable to carry out emergency responses. A CEmONC facility should be staffed with at least one obstetrician/surgeon, pediatrician, anesthesiologist, six nurses, medical technologist, and six midwives.23

Government health spending

Appropriate investment in health, if used effectively, improves health standard of the population. In turn, a healthier population generates incremental gains in economic growth, which increases the resources that institutions and households can use for health. However, those additional resources need to be distributed and used equitably to secure higher marginal gains from the poorer segment of the population.

Based on the 2003 National Health Accounts (NHA) estimates, national government spending for health was still predominantly used for the operation of public hospitals, accounting for about 70 percent. Local government expenditures for health mainly paid for the operation of general hospitals (26%) as well as public integrated care centers, including rural health units (25%), and for the provision of public health programs (21%).24 Curative care services and medical goods accounted for 55 and 22 percent, respectively, or a total of about three quarters, of the national health expenditures. The remaining health expenditures went to preventive and public health services (11 %), health administration and insurance including government regulation (9%), and health-related services such as research and training (1%). The top spenders of curative care services were households (40%), national government (17%), PhilHealth (15%), and local government units (10%).25

In 2005, the Philippines’ total health expenditure went up by 9.4 percent, from P165.3 billion in 2004 to P180.8 billion in 2005. However, the share of health expenditure to GDP was lower at 3.3 percent in 2005 compared to 3.4 percent in 2004. It is still below the 5 percent standard set by the World Health Organization (WHO) for developing countries. The WHO database showed total per

critical health interventions as a single package, backed by effective management infrastructure and financing arrangements.21

Maternal health programs and policies

To concretize its commitment to rapidly reduce maternal and neonatal mortality, the DOH issued Administrative Order No. 2008-2009 in September 2007 to implement a strategy on integrated maternal and newborn child health and nutrition (MNCHN). It aims to address service delivery, regulation, financing, and governance of the Philippines’ health system.22 The integrated MNCHN strategy, implemented in all Philippine provinces and cities, is aimed to meet the following RH indicators by 2010:

1. increase CPR to 60 percent;2. increase the proportion of pregnant women

having at least four antenatal care visits to 80 percent;

3. increase skilled birth attendance and facility-based births to 80 percent; and

4. increase percentage of fully-immunized children to 95 percent.

Through the MNCHN strategy, the Philippine government has committed itself to ensure that:

- every pregnancy is wanted, planned, and supported;

- every childbirth is facility-based and managed by skilled birth attendants; and

- mothers and their newborns are provided with proper post-partum care, as well as other relevant services included in women’s health care and the child survival package.

Essential to the MNCHN strategy are facilities that can provide basic emergency obstetric and neonatal care (BEmONC). These facilities should operate on a 24-hour basis, and are accessible within 30 minutes of travel, equipped with communication and transportation systems for referrals. Every BEmONC facility should have a physician, nurse, and midwife. Also essential to the MNCHN strategy are the comprehensive emergency obstetric and neonatal care (CEmONC) facilities which are accessible


capita expenditure on health in the Philippines was at $177 from 2000–2004. This is relatively low by comparison to neighboring countries like Malaysia ($355) and Thailand ($257).26

The government’s target to depend less on out-of-pocket payments and provide more social health insurance is still far from being realized as the share of out-of-pocket payments even increased to 49 percent while the share of social insurance payments increased only slightly to 11 percent in 2005. Based on the Health Sector Reform Agenda (HSRA), the target for out-of-pocket is 20 percent while the target for social insurance is 30 percent. Meanwhile, the share of government on health expenditure declined to 29 percent which is also below the HSRA target of 40 percent. Filipino household out-of-pocket expenditures for health were paid for care in hospitals (23%) and care by ambulatory health providers (27%), and for drugs purchased from retail outlets (50%).27

Spending for maternal health/FP/RH

Government commitments to maternal health can be monitored using financial indicators and policy approvals. Investment in maternal health programs can be tracked by measuring inputs (such as midwifery training), outputs (such as the number of midwives posted) and processes (such as the uptake of skilled delivery care).28 These indicators are necessary for planning, implementing and monitoring initiatives to improve maternal health. Based on the 2003 NHA estimates, the Philippine national government expenditures for preventive and public health services went to programs for prevention of communicable diseases (34%) and non-communicable diseases (23%), and maternal and child health (9 percent). Similarly, expenditures of foreign-assisted projects mostly paid for programs for prevention of communicable diseases (32%) and non-communicable diseases (23%), and maternal and child health (22%).29

While it is up to each country to decide on how maternity care should be organized, much depends on the availability of skilled attendants, the composite set of skills and abilities they possess, and the resources available to recruit, train and retain these staff. The principal categories of skilled attendants found in many countries include:

- Midwives (including nurse-midwives): Persons who, having been regularly admitted to an educational program duly recognized in the country in which it is located, have successfully completed the prescribed course of studies in midwifery and acquired the requisite qualifications to be registered and/or legally licensed to practice midwifery.

- Nurses with midwifery skills: Nurses who have acquired midwifery knowledge and skills either as a result of midwifery being part of their nursing curricula or through special post-basic training in midwifery.

- Doctors with midwifery skills: Medical doctors who have acquired competency in midwifery skills through specialist education and training, either during their pre-service education or as part of a post-basic program of studies.

- Obstetricians: Medical doctors who have specialized in the medical management and care of pregnancy and childbirth and in pregnancy-related complications, but not usually complications of the newly born infant. They have usually undergone additional education and clinical training to acquire these additional skills and have been certified or accredited in obstetrics.

Source: Making Pregnancy Safer: the critical role of the skilled attendant. Joint statement by WHO, ICM and FIGO, 2004: 7.

Box 1. Types of skilled attendants and the mix of skills and abilities34


For the first time, in 2007, the Philippines’ annual national budget included a specific line item for FP funding. The General Appropriations Act (GAA) of 2007 allocated P180 million to the DOH for operational costs associated with providing contraceptive services; P30 million for the routine functions of DOH in support of FP and, through congressional initiative, another P150 million to be sub-allocated to LGUs for purchasing RH commodities and conducting FP seminars.30 As of the end of 2008, less than one-third of the budgeted funds had been released to regional centers for distribution to LGUs.31 Another P1.2 billion was budgeted in 2008, again through congressional initiative, for the DOH to allocate to LGUs for procuring RH commodities for free distribution to the poor. In 2008, the government national budget allocated P19.8 billion to the DOH, of which, P386.5 million was allocated to the Commission on Population (POPCOM).

Skilled Attendance

Skilled care/attendance refers to the care provided to a woman and her newborn during pregnancy, childbirth and immediately after birth by an accredited health care provider who has at her/his disposal the necessary equipment and the support of a functioning health system, including transport and referral facilities for emergency obstetric care.32 A skilled attendant

is an accredited health professional, such as a midwife, doctor or nurse, who has been educated and trained to proficiency in the skills needed to manage normal (uncomplicated) pregnancies, childbirth, and the immediate postnatal period, and in the identification, management, and referral of complications in women and newborns.33

During pregnancy, skilled attendants monitor the progress of the pregnancy, detect complications, provide preventive measures, develop birth and emergency plans with the woman and her family and advise women on health, lifestyle and nutrition in pregnancy.

During childbirth, skilled attendants monitor the progress of labor, are vigilant for complications and stay with the women and support them in many ways. They know how to manage abnormalities such as breech delivery and, in a team of various professionals with obstetric, neonatal and anesthesia skills, they deal with complications as severe as eclampsia or obstructed labor.

In the postnatal period, the range of care varies from helping mothers and babies in breastfeeding to managing complications such as severe postpartum bleeding, infection or depression. If babies have problems, either because of preterm birth or complications of birth, they receive timely and appropriate treatment. Skilled attendants also provide counseling on postnatal contraception to the mothers.

Preventing the mother-to-child transmission of HIV is another task of skilled attendants. It starts in pregnancy with HIV testing, providing antiretroviral therapy, counseling on infant feeding and advising on safer sex practices including the use of condoms and continues in childbirth by choosing appropriate obstetric practices and supporting the mother in her choice of feeding the baby and FP counseling.35

Midwifery in the Philippines

In the Philippine Framework for Maternal Mortality Reduction,37 health workers are identified as

Box 2. Models of service delivery for midwifery and obstetric care

- Model 1: home deliveries by non-professionals with some training is common in developing countries, but as untrained birth attendants cannot manage obstetric complications, maternal mortality tends to be high

- Model 2: home deliveries by professional midwives or doctors, with systems available to refer complicated cases

- Model 3: delivery by professionals in basic obstetric facilities, with systems to refer complicated cases

- Model 4: delivery in hospitals, with comprehensive obstetric care facilities.

Source: Koblinsky, M. A. et al.


playing an integral part in achieving a lower MMR in the country. However the lack of professional health practitioners (such as doctors and nurses) in rural areas in the country is a major concern. The gap between health need and the available services is being bridged by the midwives. Although trained only to provide maternal and child health care services, midwives are currently implementing all public health programs.

Midwives constitute a large segment of the Philippine health personnel sector. In 2005, there were 16,967 government midwives in the country. Records show 150,722 registered midwives as of June 2007, of which, 3,498 were registered in 2007. Midwives work in the private or public sector, in hospitals, birthing clinics, barangay health stations, or rural health units, or they work abroad. They comprise 65 percent of the public health workforce. In the rural areas, they are the first point of contact for patients coming into the health system.38

Midwives, as the public health workers at primary health care facilities, are the main implementers of the county’s health programs. Its original focus of providing maternal and child health care has become only one of the many responsibilities they have to handle. More than 40 programs of the DOH rest on the midwives’ shoulders, including immunizing mothers and their children. In the rural areas, midwives are on-call 24 hours a day, seven days a week. This working arrangement has not changed for decades and is expected to continue in the future. Midwives and community health workers often have no equipment at all, no transport except their feet, and they work under the most difficult of conditions. Although the recommended ratio was one midwife for every 3,000 individuals, many midwives have 10,000-30,000 individuals in their catchment area.

Traditional birth attendants

Community midwives are officially labeled ‘traditional birth attendants’ (TBAs) by World Health Organization(WHO) and United Nations Children’s Fund (UNICEF) because they do not meet the international definition of a midwife and are not considered skilled attendants. Since 1990, international agencies

and academics, without robust evidence, have persuaded governments to stop training TBAs. Furthermore, TBAs, regardless whether or not they have received training, are being excluded from having a role in maternity care programs.

When the professional midwives make a sincere effort to learn about and honor local customs and traditions, when they approach local people with an attitude of respect and demonstrate willingness to work with TBAs, honoring them as colleagues, this hierarchical system can function effectively.39 In such cases, TBAs are generally very willing to advise women to go to the clinic or hospital. But when doctors and professional midwives approach the community with an attitude of arrogance, treat the TBA with disdain and punish women who attempt homebirth by treating them badly, mothers and their at-home attendants avoid the clinic or hospital at all costs. Such a situation leaves the TBA to cope with emergencies as best as she can; often until too late to seek help.40

A study in 2006 proved that facility-based births with skilled midwives and assistants working under TBA supervision effectively increased the number and proportion of women with professionally assisted births.41 These findings support the idea of a health care model, where trained TBAs work under close supervision of authorized midwives. Countries such as Malaysia that have successfully moved from the use of TBAs to skilled birth attendants even sought to include TBAs as partners and allies in the process, and constructively used their social status and relationships in the community to promote the use of skilled birth attendants.


Table 4. Evidence-based package of care required to reduce maternal mortality 42

Evidence based package of care DetailsSexual and reproductivehealth services includingfamily planning

- Providing the ability to space births and also to help prevent sexually transmitted diseases such as HIV. Up to 35% of maternal deaths could be averted through better access to family planning.43 44

- Providing adolescents with information and education about sexuality and reproduction has been shown to increase the age of sexual debut and delay the age of the 1st pregnancy.45

Care for adolescent girls46 Nutritional education and iron-folate supplements to girls aged 10-18 years in countries withhigh prevalence of anaemia ensures that women enter their reproductive years in good healthand are likely to protect them against maternal mortality and low birth weight babies.47

Antenatal care - At least 4 visits during the pregnancy.- Iron supplements – can prevent up to 23% of maternal

deaths if malaria also prevented48

- Vitamin A supplements – critical to handling infection.49

- Folate supplements.50

- Other nutrition support including the fortification of staples - at least 20% of maternal deaths are linked to poor nutrition.51

- Breastfeeding and family planning counseling.- Maternal tetanus immunization.- Preventative malaria treatment and bed nets.- Birth planning and preparation.- Antiretroviral drugs to prevent HIV transmission from

mother to child (PMTCT).Skilled birth attendants(doctors, midwives andnurses)

- Early identification of complications.- Clean and safe delivery practices.- Birth in facility.- Field responses to infections and bleeding-infection may

be involved in up to 75% of maternal deaths.52

Timely access to emergencyobstetrics services

Manage complications during labour, birth & after birth using emergency obstetric care (EMOC)principles:

- timely transport from home to facility and from facility to higher level care.

Postnatal and newborn care At least two postnatal visits by health staff:- 1st home visit within 3 days of home birth- 2nd within 6 weeks at the clinic.

Main threats: bleeding, sepsis, and anaemia.Source: World Vision and The Nossal Institute for Global Health, 2008


In the Philippines, TBAs are found in almost every barangay and in many urban neighborhoods. In these areas, they deliver the majority of births. Therefore, the potential of TBAs as FP change agents cannot be ignored. The TBA has a potential role to play in modern maternity care programs in the country. However, eliminating traditional health practices and beliefs that work against the common good should be one of the main areas to be addressed in mobilizing TBAs for them to participate effectively in maternal care programs. Instead of excluding TBAs from providing maternity care, they may be considered as resource persons, who could be involved in maternity care programs, provided they are working under close supervision from trained nurses/midwives. Hence, alternative strategies where TBAs knowledge and skills are acknowledged and incorporated within the existing health system may prove beneficial.

Policy Options and Recommendations

Some of the policy options that the Philippine Legislators’ Committee on Population and Development (PLCPD) Foundation recommends to reduce maternal mortality in the country are as follows:

Promote the rights perspective to health care

A rights perspective helps legitimize prioritizing women’s health. Strong political support and national ownership are essential to create enabling health policies, to attract resources for safe motherhood, and to ensure those resources reach groups with the highest maternal mortality. The right to health includes entitlements to a range of health interventions which have an important role to play in reducing maternal mortality. The government has an obligation to provide goods and services in order to prevent maternal mortality. These include:

- Emergency obstetric care (EmOC);- A skilled birth attendant;- Education and information on sexual and

reproductive health;- Other sexual and reproductive health care

services, such as family planning services;

- Primary health care services.

Provide clear policy framework

A comprehensive approach to accelerating progress in maternal health begins with a clear national policy framework that encompasses multiple levels, from presidential decrees and statutory laws to health systems’ policies, standards, and protocols. Many laws and policies that fall completely outside the health sector also have a bearing on maternal health. These include laws and regulations relating to education, social welfare, transport, justice, finance, employment, etc. Government has the responsibility to ensure that the laws, regulations, and policies that affect particular aspects of maternal health are harmonized and are in line with human rights enshrined in national constitutions, regional and international human rights treaties, and international consensus documents. The Philippine Congress should enact the proposed Reproductive Health and Population Development Act of 2008 which aims to promote information and access to natural and modern FP; breast feeding, prevention of abortion and management of post-abortion complications; adolescent and youth health; prevention and management of reproductive tract infections, HIV/AIDS and STDs; elimination of violence against women; counseling; treatment of breast and reproductive tract cancers; male involvement and participation in RH; and RH education for the youth.

Integrate family planning in safe motherhood program

Family planning can prevent many maternal deaths by helping women prevent unintended pregnancies and by reducing their exposure to the risks involved in pregnancy and childbirth. FP allows women to delay motherhood, space births, prevent unsafe abortions, protect themselves from sexually transmitted infections (STIs), including HIV/AIDS, and stop childbearing when they have reached the desired family size.

More lives would certainly be saved if all women had access to good prenatal, delivery, and


postpartum care. It must also be acknowledged that the interventions to reduce maternal death also significantly contribute to reducing newborn mortality.

Make emergency obstetric care available to all women

In addition to facility based skilled attendance, a well functioning health system with provision of equipment, drugs and other supplies is needed for the effective and timely management of delivery complications, which may lead to maternal deaths. Recently, much emphasis has been on making emergency obstetric care (EmOC) available to all women, who need it. It does not imply that all births should take place in well-equipped health facilities, but only that if a pregnant woman develops complications, she should be able to access essential obstetric care. To ensure improved access to EmOC, a well functioning referral system is mandatory. This means overcoming delays in recognition of complications and in gaining timely access to appropriate EmOC facilities.53 Additionally, for those women who develop obstetr ic complications, a health worker (or team of health workers) who is trained, authorized, and supported to deliver the emergency care required has to be present.

Promote healthy timing and spacing of pregnancy

Communication, counseling and services for adolescents should focus on the health risks associated with the timing of a first pregnancy and birth. Healthy timing and spacing of pregnancy (HTSP) is an intervention to help women and families delay or space their pregnancies to achieve the healthiest outcomes for women, newborns, infants, and children, within the context of free and informed choice.

Specific recommendations for HTSP:54

- Implement HTSP behavior change c o m m u n i c a t i o n a n d c o u n s e l i n g interventions as an integral risk prevention strategy in all FP, child and maternal health communications and client counseling protocols.

- Ensure that the two 2006 WHO pregnancy spacing recommendations, as well as information on the specific health benefits associated with the healthy timing and spacing of pregnancy are included in all communications and protocols.

- Develop or strengthen pregnancy delay or spacing services and communication activities for young (15-29 years) clients.

- To achieve a more balanced method mix, help families understand that long-acting and intermediate methods (IUDs and injectables) are safe, and can effectively help them achieve their spacing preferences.

Reduce impact of unsafe abortion

The ICPD commitment to address the problem of unsafe abortion is reflected in Paragraph 8.25 in the ICPD PoA, which acknowledges that improving abortion-related care is an essential strategy for improving women’s health. On this background and based on years of advocacy by NGOs on the need to integrate sexual and reproductive health objectives into the MDGs,55 it was in 2005 suggested that the risks women face from unplanned births and unsafe abortion should be incorporated into the monitoring of the MDG framework.56 In October

Box 3. WHO recommendations for birth spacing

Birth spacing after a live birth: After a live birth, the recommended interval before attempting the next pregnancy is at least 24 months in order to reduce the risk of adverse maternal, perinatal and infant outcomes.

Birth spacing after an abortion: After a miscarriage or induced abortion, the recommended minimum interval to next pregnancy is at least six months in order to reduce risks of adverse maternal and perinatal outcomes.Source: World Health Organization, 2006 Report of a WHO Tech-

nical Consultation on Birth Spacing.


2006, the United Nations’ General Assembly gave its endorsement to include universal access to reproductive health by 2015 as one of the international community’s Millennium Development targets.57

Revise midwifery law

Proposed amendments to the midwifery legislation in the country aim to enhance the standards of the profession by raising the passing rate in licensure examinations and expanding the responsibilities of midwives to perform their functions.

Promote entrepreneurship among midwives

Midwives in the Philippines can be trained to open and manage midwife clinics to provide affordable, quality, convenient health care to clients in the lower- and middle-income markets.

Promote partnership with traditional birth attendants

In spite of strong advocacy for facility based deliveries, some Filipino women will choose to deliver at home either with a skilled attendant, a community health worker (CHW) or a TBA. For mothers who deliver at home, facility based obstetric care alone is not likely to be a credible strategy for reducing maternal death. Therefore, along with the strategy of aiming at increasing the number of health facility based deliveries, some preventive functions of basic care targeting women who prefer to deliver outside the health facilities should be developed. Such strategies have been evaluated and found to be associated with low maternal mortality ratio in the Netherlands and Malaysia.58

In practical terms TBAs can help in the provision of skilled care to women and newborns by:

- serving as advocates for skilled attendants and maternal and newborn health needs;

- encouraging women to enroll for essential pre- and postnatal care and to obtain care from a skilled attendant during childbirth

- helping women and families to follow up on self-care advice and other

recommendations (nutrition, treatment, dietary supplementation, immunization, scheduled appointments, plan for births and emergencies, etc.);

- encouraging the involvement of the male partner in the care of the woman and their newborn;

- disseminating health information through the community and families (danger signs, where and how to seek care, healthy life styles, where to seek assistance for other RH needs such as FP, neonatal immunization, etc.) where this role is not the mandate of the skilled attendant;

- giving social support during and after delivery, either as a birth companion or by supporting the household while the woman is away for childbirth;

- informing the skilled attendant about women who have become pregnant in the community so that the skilled attendant can make direct contact with them;

- serving as a link between families, communities and local authorities and the RH services; and

- encouraging community involvement in the development/maintenance of the continuum of care.

Strengthen the health system

Key elements of the Philippine health system that must be strengthened include sufficient numbers of health providers with midwifery skills, and immediate access to emergency obstetric care for all women who experience a complication in pregnancy or childbirth. Maternal mortality reduction is, in the first place, a matter of strengthening health systems, including human resources. It is access that counts: to skilled attendance, to emergency obstetric care, to family planning and to safe abortion. In addition, innovative community approaches are important to enhance local ownership, develop local solutions and bridge the gap between communities and services. Health systems research, finally, is needed to generate new evidence and keep fine-tuning national policies to realities.


Conclusion

Increasing access to skilled and timely care is a key to reducing the toll of maternal deaths. Failures occur at household and community level, through poverty, gender bias, and lack of awareness on the needs of pregnant women. They occur at: (1) service delivery level through lack of accessible, well functioning, and staffed and resourced facilities; and at (2) policy and systems level through poor planning, management and supervision, and lack of political commitment. Attention also needs to be given to cost effective ways of measuring and monitoring maternal mortality and morbidity.

Almost all maternal deaths could be prevented if skilled midwifery care was available to mothers during pregnancy and childbirth, with effective referral systems in place for emergencies. However, in many places in the Philippines, the services of skilled birth attendants are not available and TBAs are women’s only source of care. TBAs can provide culturally appropriate nurturing in the community setting, offer a first-line link with the formal healthcare system, and provide some simple services such as the distribution of nutrition supplements. A useful strategy in a range of settings has been to train TBAs to recognize problems during delivery and, when necessary, to guide women to and through the formal healthcare system. Where TBA training is undertaken, it should be part of a broader strategy that includes a built-in mechanism for referral, supervision, and evaluation59.

Underlying high levels of maternal death and disability is the failure to assure women’s rights and gender equality. Women’s low status and lack of power, poor access to information and care, restricted mobility, early age of marriage, and the low political priority and resources given to their health all contribute to high maternal mortality ratios. In the Philippines, overcoming this means challenging the cultural and political norms and legal frameworks that limit women’s ability to make informed choices about, and take appropriate actions to ensure, healthy sexual and reproductive lives.

The Philippine government should also start considering other options in addressing the issue on population growth, such as the pending bills on RH in Congress. One of those is the proposed Reproductive Health and Population Development Act of 2008. Essentially, a good and progressive policy should be able to empower the poor by affording them access to pertinent information on RH as well as important services, particularly on maternal health. This should coincide not only with the goal of sustainable human development but poverty reduction as well, considering that higher fertility occurs more often in lower-income groups60.

Finally, the maternal health (Goals of the the MDGs)will not be met without rapid action to:

- increase awareness of the nature and scale of the problem, making it visible to politicians, professionals, and the public thereby creating a powerful catalyst for change;

- increase investment in strengthening health systems and in improving access to RH services generally and to maternal health services specifically; and

- address the wider social, cultural, and economic barriers to better maternal health, including the unequal status and rights of women.


Endnotes1 United Nations Millennium Declaration. Fifty-fifth

Session of the United Nations General Assembly. New York: United Nations; 18 September 2000. (General Assembly document, No. A/RES/55/2).

2 Commission on Population (POPCOM). State of the Philippine Population Report: Time to Act: Needs, Options, Decisions, State of Philippine Population Report 2000, Mandaluyong City: POPCOM, 2001.

3 National Statistics Office (NSO), 2006 Family Planning Survey.

4 WHO. op cit. 5 Ibid.6 NSO, 2006 Family Planning Survey, Manila: NSO,

2006.7 NSO, 2008 National Demographic and Health Survey,

Preliminary Report.8 Pulse Asia, Ulat ng Bayan survey media release on

family planning, March 2007. Available at9 http://pulseasia.com.ph/pulseasia/story.asp?id=545.

Social Weather Stations, SWS 4th Quarter 2004 survey report on family planning for the Department of Health (DOH), 24 Feb. 2005.

Available at http://www.sws.or.ph.10 Singh S et al., Adding It Up: The Benefits of Investing

in Sexual and Reproductive Health Care. New York: The Alan Guttmacher Institute and United Nations Population Fund, 2003.

11 Government of the Philippines. Philippines Progress Report on the Millennium Development Goals. Manila: Government of the Philippines and United Nations, 2003.

12 Save the Children, State of Filipino Mothers 2008: Saving Mothers’ Lives, Ensuring Children’s Survival, March 2009.

13 Conde-Agudelo A, Rosas-Bermúdez A, and Kafury-Goeta AC, “Birth Spacing and Risk of Adverse Perinatal Outcomes: A Meta-analysis,” Journal of the American Medical Association 2006;295:1809-1823.

14 Da Vanzo, J., Razzaque A, Rahman M, Hale L, Ahmed K, Khan MA, Mustafa G and Gauzia K, “The Effects of Birth Spacing on Infant and Child Mortality, Pregnancy Outcomes, and Maternal Morbidity and Mortality in Matlab, Bangladesh,” Rand Corporation: Rand Labor and Population Working Paper Series, WR-198, October 2004.

15 Darroch JE, Singh S, Bal H, Cabigon JV, “Meeting women’s contraceptive needs in the Philippines,” Issues in Brief, Alan Guttmacher Institute 2009;1:1-8.

16 Jansen WH, “Extending Service Delivery (ESD) Project: Country profile: Philippines,” Washington DC: U.S. Agency for International Development (USAID) Bureau for Global Health, (n.d),

17 National Statistics Office, op cit.18 Philippines midterm Progress Report on the

Millennium Development Goals, page 34.19 The Health Sector Reform Agenda (HSRA) does not

include two priority areas of human resource development, or improving the health information systems. HSRA-plus will include these two cross-cutting areas.

20 Asian Development Bank, Technical Assistance to the Republic of Philippines for the Support for Health Sector Reform (TAR: PHI 39066), Sept 2005

21 Department of Health, Philippines website, < http://www.doh.gov.ph/fourmulaone>.

22 Save the Children, op cit.23 Ibid.24 National Statistical Coordination Board (NSCB), 2003

Philippine National Health Accounts, NSCB, 2004, in Racelis, Rachel H “The National Health Accounts of the Philippines: Continuing Development and New Findings, “Philippine Journal of Development, FindArticles.com, <http://findarticles.com/p/articles/mi_qa5519/is_200601/ai_n21407228/>.

25 Ibid.26 World Health Organization (WHO), National Health

Accounts, World Health Statistics, 2006.27 NSCB, 2004, op cit.28 Wardlaw T and Maine D, “Process indicators for

maternal mortality programmes,” in Reproductive Health Matters. Safe Motherhood Initiatives: Critical Issues, Oxford: Blackwell, 1999:24-30.

29 Ibid.30 Darroch JE et al, op cit.31 Office of the Secretary, Department of Health

(Philippines), Department memorandum 2008-0272, Dec. 16, 2008. Available at <http://home.doh.gov.ph/dm/dm2008-0272.pdf>.

32 World Health Organization (WHO), “Making pregnancy safer: the critical role of the skilled attendant,” Joint statement by WHO, ICM and FIGO, 2004:1. (This revised definition has been endorsed by the United Nations Population Fund and the World Bank.)

33 Ibid.34 WHO, 2004, op cit.35 WHO. 2005, op cit.


PEOPLE COUNTPLCPD POLICY BRIEF 2009

A publication developed by the Philippine Legislators’ Committee on Population and Development Foundation, Inc. (PLCPD) with support from United Nations Population Fund.

2/F AVECSS Building, #90 Kamias Road. cor. K-J Street, East Kamias, Quezon City 1102, PhilippinesTel. nos.: (+632)925-1800 • (+632)436-2373 E-mail: [email protected] Website: http://www.plcpd.org.phExecutive Director: Ramon San Pascual, MPHEditors: Floreen M. Simon, Ernesto Almocera, Jr. and Romeo C. DongetoLayout: Dodie Lucas

PLCPDSince 1989

Philippine Legislators’ Committee on Population and Development Foundation, Inc.

48 Black R et al, “Maternal and child undernutrition: global and regional exposures and health consequences,” Lancet 2008;371:243-260.

49 West K et al, “Double blind, cluster randomised trial of low dose supplementation with vitamin A or beta carotene on mortality related to pregnancy in Nepal,” BMJ 1999;318:570-75.

50 Evidence is building to suggest that child and maternal mortality can be further reduced by additional micronutrient supplementation beyond iron, folate and Vitamin A e.g. see Shankar A et al, “Effect of maternal multiple micronutrient supplementation on fetal loss and infant death in Indonesia: a double-blind cluster-randomised trial” Lancet 2008;371:215-27.

51 Black R et al , op cit.52 Costello A et al, “An alternative strategy to reduce

maternal mortality” Lancet 2006;368:1477-9.53 Thaddeus S and Maine D., “Too far to walk: maternal

mortality in context,” Soc Sci Med 1994;38:1091-110.54 Jansen, op cit.55 Rasch, V, Maternal death and the Millenium

Development Goals,” Dan Med Bull 2007;54:167-9.56 Technical consultation on reproductive health

indicators, summary report 2006, Geneva: World Health Organization, 2006.

57 Family Care International, <http://www.familycareintl.org/en/issues/24>, 2007.

58 Koblinsky M, Campbell O, Heichelheim J., “Organizing delivery care: what works for safe motherhood?” Bull World Health Organ 1999;399-406.

59 Reduction of maternal mortality. A joint WHO/UNFPA/UNICEF/World Bank statement, Geneva: WHO, 1999.

60 Garcia P and MJ Vital, “Living on the edge,” BusinessWorld, 24 July 2009. Available at http://www.bworldonline.com/BW072409/content.php?id=059.

36 Koblinsky, M. A., C. Conroy, N. Kureshy, M. E. Stanton, and S.Jessop, Issue in Programming for Safe Motherhood, Washington, D.C.: MotherCare/JSI, 2000.

37 Department of Health, Philippine Framework for Maternal Mortality Reduction. Available at http://doh.gov.ph/mmr/mmr_framework.htm

38 International Confederation of Midwives , “Midwifery in the Philippines,” 2008.

39 Davis F, “Some perspectives on global issues in midwifery,” Midwifery Today, in Women’s International Network News, Summer 2000;26.3:22-23

40 Ibid.41 Koblinsky M, Matthews Z, Hussein J, Mavalankar D.,

Mridha M.K., Anwar I., et al, “Going to scale with professional skilled care,” Lancet 2006;368:1377-86.

42 World Vision and The Nossal Institute for Global Health, University of Melbourne, “Reducing maternal, newborn and child deaths in the Asia Pacifc: Strategies that work.” Melbourne: World Vision and The Nossal Institute for Global Health, University of Melbourne, 2008:4.

43 Department for International Development (DFID), “DFID 2004 Maternal health strategy: Reducing maternal deaths: evidence and action,” London: DFID, 2007:9.

44 Bernstein S. et al, “Sexual and reproductive health: completing the continuum,” Lancet 2008;372:1225-6.

45 Bearinger L. et al, “Global perspectives on the sexual and reproductive health of adolescents: patterns, prevention, and potential,” Lancet 2007; 369:1220-1231.

46 A more extensive care continuum advocated by some authors includes adolescent health support. For example see Kerber K et al, “Continuum of care for maternal, newborn, and child health: from slogan to service delivery” Lancet 2007;370:1358-69.

47 World Health Organization, Regional Office for South-East Asia (WHO-SEARO), Adolescent Nutrition: A Review of the Situation in Selected South-East Asian Countries, New Delhi: WHO-SEARO, 2006:47-50.

Documents

Philippine Government Policies in Reducing Maternal Mortality