Banning home births to worsen, not improve maternal death rate – health groups

In Nueva Ecija, a woman who was about to give birth walked and crossed a river to get to the nearest birthing facility. The mother and the child died before reaching the nearest birthing station. Because giving birth at home in Quezon City is prohibited, the mother who was about to give birth was not brought immediately to the hospital because the family has no money. Her twins died.

By ANNE MARXZE D. UMIL
Bulatlat.com

MANILA – The statistics is glaring. Two hundred and twenty one mothers die in every 100,000 live births, according to the 2011 data of the National Statistics Office. It has increased from 162 in 2009. Purportedly to address the problem of maternal deaths, the Department of Health (DOH) implemented a policy discouraging home births assisted by traditional birth attendants (TBAS) or hilots.

The Department of Health passed Administrative Order 2008-0029 known as “Implementing Health Reforms towards Rapid Reduction in Maternal and Neonatal Mortality,” called the “No Home Birthing Policy,” during the administration of former president Gloria Macapagal Arroyo. This policy was also intended to enable the Philippines to achieve its commitment to the Millennium Development Goals (MDGs). The MDGs include lowering maternal mortality rate to 52 per 100,000 live births in 2015.

Under the administration of President Benigno Aquino III, the DOH released its updated version of AO 2008-0029 that is now known as maternal, newborn, child health and nutrition (MNCHN) strategy. It has published a 200–page manual of operations on March 27, 2011. The MNCHN aims to guide local government units (LGUS), as well as national agencies in the implementation of AO 2008-0029 or the MNCHN Strategy, especially to populations that are most at risk from maternal and child deaths. “In recognition of the differences in local conditions and constraints, the LGU should design the implementation of the MNCHN strategy based on their local context,” the MNCHN manual of operations read.

In an interview with a television talk show, DOH’s officer-in-charge of National Center for Disease Prevention and Control Dr. Irma Asuncion said there is no such thing as a “No Home Birthing Policy” but the DOH is advocating for facility-based deliveries and deliveries should only be attended by professional birth attendants.

However, local government units came up with their own policies or ordinances in line with the MNCHN strategy produced by the DOH.

Local government policies on home births

According to Dr. Geneve Rivera, secretary general of Health Alliance for Democracy, trained traditional birth attendants (TBAs) in a lot of provinces are prohibited from facilitating childbirths at homes. She also said the DOH no longer trains TBAs.

In Davao, Rivera said, kits for assisting childbirths were taken away from traditional birth attendants. This is because the MNCHN strategy prohibits TBA-assisted deliveries. The MNCHN manual of operations states, “The adoption of the MNCHN Strategy in each identified priority province or city requires a number of executive issuances and/or legislations to facilitate and sustain its implementation….the policy directive will promote and enforce regulations supportive of MNCHN goals and objectives, such as: (a) promotion of facility-based deliveries, and prohibition of TBA-assisted deliveries;…”

To comply with the MNCHN strategy, some LGUs have implemented city ordinances against home birthing. In Quezon City, home to many urban poor communities, the local government has implemented City Ordinance No. 2171, “An ordinance prohibiting home births in Quezon City, Prohibiting traditional birth attendants to deliver babies and requiring all professional health practitioners to deliver babies only in health facilities and providing penalty for violation thereof.”

The municipality of Danao in Bohol also issued Municipal Ordinance No. 2011-0204, “An ordinance requiring all pregnant women to give birth at designated municipal birthing home/clinic within the municipality of Danao, Bohol.” In this ordinance, the TBAs are tasked to bring the laboring mother to the nearest birthing clinic where she could be attended to by skilled birth attendants. “Guidelines on the role of traditional hilots limits them to supportive care only. It is mandatory that prenatal delivery and post natal services for mothers should be handled by licensed physicians, nurses or licensed midwives.”

Municipality of Minalin in Pampanga also implemented an ordinance discouraging home-based deliveries.

The municipality of MacArthur, Leyte’s Ordinance No. 4-2010 penalizes TBAs, who would perform home-based child delivery. The ordinance also provides a service charge of P2,500 to pregnant women who would deliver their babies at the municipal health center.

Progressive health groups argue that imposing such policy will not necessarily result in a decrease nor will it solve the problem of maternal mortality rate. For the Council for Health and Development (CHD), such policy will only increase the incidence of maternal deaths, especially in remote rural areas where hospitals are hours away from where people live.

Rivera meanwhile said TBAs should be seen as complementary to public health workers in rural areas and should be provided trainings and tools for more effective and efficient provision of basic health services.

More deaths

Grace Cuasay, a registered midwife and director of Health, Education, Training and Services Department of CHD expressed concern on the implementation of DOH’s policy.

“Reports coming from our member community-based health programs in the provinces revealed that the lives of pregnant women are placed in great danger because of the new policy,” Cuasay said.

She said that in Nueva Ecija, a woman who was about to give birth walked and crossed a river to get to the nearest birthing facility. The mother and the child died before reaching the nearest birthing station. In Iloilo, a Basic Emergency Obstetric and Newborn Care (Bemonc) facility serves 45 villages and pregnant women have to travel at least three days to reach the birthing station.

A Bemonc facility, which is based in hospitals, rural health units, barangay health stations, lying-in clinics or birthing homes, can perform six signal obstetric functions (1) parenteral administration of oxytocin in the third stage of labor; (2) parenteral administration of loading dose of anti-convulsants; (3) parenteral administration of initial dose of antibiotics; (4) performance of assisted deliveries (Imminent Breech Delivery); (5) removal of retained products of conception; and (6) manual removal of retained placenta.

According to the manual of operations of the MNCHN, Bemonc facilities operate on a 24-hour basis with a staff complement of skilled health professionals such as doctors, nurses, midwives and medical technologists. A Bemonc based in RHUs, BHS, lying-in clinics, or birthing homes can either be a stand-alone facility or composed of a network of facilities and skilled health professionals capable of delivering the six signal functions, the MNCHN manual of operation said.

However, according to Nars ng Bayan, which is currently doing a research on the situation of health workers in the province, health professionals such as doctors, nurses, midwives are lacking in rural areas. In its initial findings, the group said in Lubao, Pampanga where there are 45 barangays, there is only one doctor and a midwife. There are no nurses.

Eleonor Nolasco, president of Nars ng Bayan said their on-going research shows that some birthing facilities in the provinces have no water, no medicines and worse – no attending health professionals.

Also according to the CHD, a national organization of community-based health programs in the Philippines, only 17,000 of the country’s total 41,000 barangays (41 percent) have government established health stations, which are often ill-equipped with facilities, medicines and staff. There is only one barangay midwife who services three to five barangays (1 midwife; 6,578 populations).

“This policy of the DOH does not even recognize the situation of mothers in rural and urban areas. Instead of forcing these mothers to go to the birthing facility, which is kilometers away from their houses, the DOH should strengthen and enhance the skills of community health workers or the traditional birth attendants who have been practicing facilitating deliveries at homes for years,” said Nolasco.

Expensive

Pregnant women, especially those who are poor, prefer to give birth at home because of costly deliveries in hospitals.

According to Delia Naldo, 57, a resident of barangay Militar in Proj. 8, Quezon City, her neighbor’s twins died because of complications. She said that because giving birth at home in Quezon City is prohibited, the mother who was about to give birth was not brought immediately to the hospital because the family has no money.

“She was seven months pregnant and she was not brought to the hospital immediately because of lack of money. When they finally brought her to the East Avenue Medical Center (EAMC), one baby had died already while the other one was saved at the intensive care unit,” Naldo said adding that days later the other twin died too.

She said the family had a total bill of P104,000 ($26,000) at the EAMC. They have been asking for assistance from politicians and government officials, but the money they were able to raise was still not enough to pay for the hospital bill. Naldo said the death certificates of the twins were not released by the EAMC because of the unpaid hospital bill.

In the television interview, Asuncion also admitted that one factor why mothers prefer to give birth at home is the expensive cost of giving birth in hospitals.

While in rural areas, hospitals are way too far from villages and birthing stations are ill-equipped, here in Manila, the cost of giving birth in hospitals or in lying-in centers is expensive.

The Dr. Fabella Memorial Hospital, the maternal and newborn tertiary hospital in Manila charges P3,000 ($75) to P5,000 ($125) for normal delivery. Fabella is where indigent patients go because of the supposed “affordable and accessible health services.”

At the Tondo Medical Center, normal delivery costs P1,500 ($37.50) to P2,000 ($50). At the Philippine General Hospital, patients from the charity ward are also charged about P1,500 for normal delivery.

Aside from hospital charges, mothers still have to find the money to buy medicines.

Private lying-in clinics also require payments from P3,000 ($75) and above. This, said the Nars ng Bayan, has become a business for some midwives. One anecdote from their researcher revealed that in one province, pregnant mothers who give birth after 5 p.m. are no longer accommodated in the lying-in clinic of the barangay health center. A midwife, working in the said health center, refers them to a private lying-in center. The midwife turned out to be the owner of the said private lying-in center. Some private lying-in centers are operated by registered midwives.

Meanwhile, Dr. Geneve Rivera stressed that mothers die not only because of the complications of giving birth but also because health services, which are supposedly free, are now far beyond the reach of the poor.

Rivera also pointed out, “A pregnant woman can die because she is not eating the right food and this is because her husbands’ salary remains low or has no work or no land to till. Working mothers have no rightful benefits from their employers or are being deprived of basic health services by the government.”

She added how the government pushes mothers to the wall at the looming privatization of government hospitals.

Address the present problem

Cuasay said to decisively address the problem, the government should admit that home birthing is not the primary reason why maternal mortality rate is high. “A significant decrease in the maternal mortality rate is impossible to achieve in a reactive public health care system that loyally subscribes to foreign-influenced programs like the “no home birthing policy.”

Rivera also slammed the DOH statement that poor patients can avail of free health services through Philhealth. She pointed out that not all hospitals are Philhealth accredited. Also not all patients are members of Philhealth.

Cuasay said the government should address the present problems afflicting health services in the Philippines.

“The government should provide more doctors, nurses and midwives in rural communities, until the World Health Organization prescribed ratio of one midwife to 500 populations is met,” Cuasay said.

The groups also calls on the government to allot five percent of the gross domestic product to the health services and to stop privatization of government hospitals.