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'Midwifery in the Philippines: 'a laudable service' but there are issues and challenges: Alice de la Gente, former President of the Integrated Midwives Association of the Philippines (IMAP), wrote about midwives' key healthcare role in this country.


ICM learned with great sadness of Alice de la Gente's death in November 2008. Alice was President of the ICM 1996-1999, and played a major part in hosting the 1999 Manila Congress. This article was written by Alice earlier in the year and is now published as a tribute to her life and achievements. The Philippines is a signatory to the 2000 Millennium Declaration on the global agenda for development by 2015. Among the eight Millennium Development Goals (MDGs), the country is said to be on schedule except with Goal 5, which aims to improve maternal health by reducing the maternal mortality ratio (MMR) by three quarters between 1990 and 2015. Using data from the 1993 National and Demographic Survey as a base, the MMR at that time of 209 per 100,000 live births, should be reduced by 2015 to 53. In fact, only slow progress has so far been observed. The 2006 Family Planning Survey estimated an MMR of 162 per 100,000. This is a decrease of only 22% from the base estimate. There is a need to redouble efforts to achieve the desired MDG target on maternal mortality.

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

Indeed, the midwives in the country play a key role in delivering patient-focused services that are accessible, affordable and appropriate to the needs of patients as individuals and their families. The midwifery profession is central to the delivery of an effective health service, particularly in the rural areas. The midwifery profession, however, is facing issues that may constrain their effectiveness.

Midwives in the Philippines

Midwives constitute a large segment of the health personnel sector. Records show 150,722 registered midwives as of June 2007, and there were 3,498 newly registered midwives in 2007. Midwives work in the private or public sector--in hospitals, birthing clinics, barangay (village) health stations, or rural health units--or they work abroad. They comprise 65% of the public health workforce. In the rural areas, they are the first point of contact for patients coming into the health system. In 2005, there were 16,967 government midwives in the country, delivering frontline services in 15,436 barangay health stations and 2266 rural health units.

The laudable service of the midwives in the rural areas does not go unnoticed. Various titles have been given to them such as 'barefoot doctors', and 'diamonds in the health care field'. Recently, they have been hailed as 'modern health heroes'. Dr Lulu Bravo, professor of paediatrics and vice chancellor and executive director of the University of the Philippines' National Institute of Health in Manila, said, "Midwives are the new health care heroes. Without the midwives, we're left with nothing.".

Issues and challenges

In a Round Table Discussion on the Millennium Development Goal 5: Reducing Maternal Mortality held at the Asian Institute of Management in July 25, 2007, midwives were identified as the answer to further lowering the MMR in the country, particularly in the rural areas. The only hindrance to the full participation of the midwives is the 1992 Midwifery Law in the Philippines, which limits the surgical or operational participation of midwives.

Midwives, as the public health workers at primary health care facilities, are the main implementers of health programmes. Their original focus of maternal and child health care has become only one of the many responsibilities they have to handle. More than 40 programmes of the Department of Health rest on the midwives' shoulders, including immunising mothers and their children for diarrhoea, malaria, dengue, TB-DOTS (Tuberculosis-Directly Observed Treatment Short-course), tetanus, hepatitis B, diphtheria, polio and measles; counselling mothers, and educating couples on family planning, nutrition and pregnancy.

In the rural area, 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, many midwives have 10,000-30,000 individuals in their catchment area.

Working conditions

Midwives endure poor and risky working conditions. To illustrate the dangers of the work of a midwife in the Philippines, here are few cases reported in a national daily:

* One early morning in 1993, Teresita Dodon braved heavy rains to travel to Sablan, Benguet, for her door-to-door immunization project. She was crossing the highway at Camp Dangwa when she was sideswiped by a bus. Dodon's life was ended by the accident, but it became the inspiration for her fellow midwives. For her outstanding work, she was recognized posthumously by the Civil Service Commission who gave her the Dangal (Honor) award. The inscription read: "As she lay dead on the road, she was still protectively clutching the vaccines and medical paraphernalia, the tools of the trade she loved so much."

* Aeta midwife Jeana de la Cruz, who conducts prenatal checkups and immunizations in the mountain villages of Castillejos, Zambales, has described the difficult journeys she makes to attend to women with complicated pregnancies, who, despite their condition, have to ride on carabao (buffalo)-drawn carts. She received an award from Johnson & Johnson in 1999.

* Edna Beguia, 54 and a midwife for 30 years, had to attend a childbirth in Real, Quezon with half her body submerged in floodwaters. The day saw a flash flood engulfing Real, killing hundreds of men, women and children, and wiping out the main health centre. A number of women had their babies on that day; three of them were attended by Beguia on her makeshift delivery table.

Proposed revision of midwifery law

Proposed amendments to the midwifery legislation aim to enhance the standards of the profession by raising the passing rate in licensure examinations and expanding the responsibilities of midwives to perform such functions as dispensing of oral and parenteral oxytoxic drugs, injection of vitamin K, newborn screening, and basic life saving.

Promotion of entrepreneurship among midwives

Midwives are trained to open and manage Well-Family Midwife Clinics (WFMC) to provide 'affordable, quality, convenient health care to clients in the lower- and middle-income markets.' The clinics' start-up had been funded in previous years by foreign donors and operated in partnership with the international NGO John Snow Inc.

Further professionalisation of midwifery

Midwifery education was introduced in 1922 as a one-year course. It now takes two years, with graduates required to take a board examination. Efforts to upgrade midwifery to a four-year course with a higher professional level proved successful. The BSc in Midwifery will take effect in the year 2008-2009 following Memorandum 33 (Series of 2007) issued by the Commission on Higher Education.
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Publication:International Midwifery
Geographic Code:9PHIL
Date:Dec 1, 2008
Previous Article:Parliamentary 'Action on Maternal & Newborn Health'.
Next Article:International Council on Women's Health Issues (ICOWHI) Conference held in Gabarone, Botswana, 9-11 July, 2008.

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