IRIN/Manila

Varied implementation of a Department of Health (DOH) policy advocating health facility-based delivery under the care of a skilled birth attendant (SBA) has health officials and advocates worried that the policy may be doing more harm than good.

The DOH policy known as the Maternal, Newborn, and Child Health and Nutrition (MNCHN) was issued in March 2011 to address the country’s stagnant maternal mortality ratio (MMR).

“It is clear that having births in a healthcare facility under an SBA is critical in ensuring safety of both mother and child, and thus lowering maternal death,” said Honorata Catibog, director for the DOH Family Health Office.

According to the 2011 Family Health Survey (FHS), the number of Filipino women who died from childbirth rose from 162 in 2009 to 221 in 2011.

The 2008 National Demographic Health Survey (NDHS) shows that 56% of births take place at home under the care of a traditional birth attendant (TBA) known locally as a ‘hilot’.

With little or no medical training, TBAs are not equipped to diagnose pregnancy complications or carry out emergency obstetric care procedures.

“Let me be clear that there is no such thing as a policy prohibiting home births. This is not realistic. We are simply advocating and encouraging facility-based delivery,” said Catibog.

With healthcare reform introduced in 1991, management and delivery of healthcare systems were transferred from the national DOH to local government units (LGU), giving LGUs the autonomy to customise the implementation of national policies such as MNCHN.

In the province of Samar, southeast of the country’s biggest island of Luzon, Samuel Baldono, a municipal health officer, says an incentive of $8-10 is given to the TBA for referring and accompanying the woman to the health facility to have her baby delivered at no cost to her.

“We have seen a dramatic increase in facility-based delivery since this incentive was implemented and a corresponding decrease in maternal death. For the past two years, facility-based delivery has risen to about 89% and we have had zero maternal deaths,” said Baldono. However, some municipalities in other parts of the country have reportedly implemented punitive measures, punishing either the mother or the TBA for pursuing a home birth.

In Sultan Kudirat, in the southern island of Mindanao, a birthing policy pushing for facility-based delivery was passed with an imposition of a $50 fine for home births.

“There was a lot of protest, so the fine was never implemented, but the provision is there,” said Renan Kasan, an area programme officer with the UN Population Fund (UNFPA).

Amina Evangelista, executive director of Roots of Health (ROH), an NGO in the island province of Palawan in southwest Philippines, reports similar difficulties.  

ROH provides SBA assistance both for homebirths and deliveries in their facility, but Evangelista says they have been getting fewer requests for homebirth delivery. “We’ve been told by patients that homebirths are forbidden…

“It’s incredibly frustrating. Some women are afraid to give birth in a hospital or simply cannot afford it. We can offer SBA assistance to make homebirths safer, but now my clinical staff are afraid they will lose their licence if they facilitate home births,” said Evangelista.

“We have heard that there are some areas implementing punitive measures, but to date, we know of no one who has been jailed or fined for a home delivery,” said Ugochi Daniels, UNFPA country director.

“However, what we are worried about is maternal deaths that occurred at a homebirth going unreported because of fear and confusion about this policy,” added Daniels.

Junice Melgar, a women’s rights activist and executive director of the Likhaan Centre for Women’s Health in Manila, said: “Yes, facility-based deliveries are safer, but a woman should have the right to choose to give birth at home if she is well-informed of its risks. Right now, there is just a lot of confusion. The DOH should be clear about its directives and its provisions.”