April - May 2008
2015 or bust?

Making sure Mama makes it

VALLEHERMOSO, CARMEN, BOHOL — Had she been in the same situation eight years ago, Jesusa Panes would have probably just given birth at home, even without her husband in sight, and even if her neighbor the hilot (traditional birthing attendant) happened to be drunk. But things have not been the same for expectant mothers in this town since 2002, and so when the child in her belly starting demanding to be let out, Panes began trudging toward the birthing center that was several minutes away by foot from her home.

The drunken hilot did his duty by swaggering behind her, seeing to it that she got to the center safely. Carmen is in fact the only town in Bohol that has legislated that all mothers must give birth at designated birthing facilities in five barangays or at the town’s birthing center (rural health unit or RHU), a P2.5-million, sprawling facility that offers first-class service for very low fees. Carmen’s laws also say a hilot should bring laboring mothers to the nearest birthing clinic to ensure a comfortable and safe delivery. And even if a hilot is trained, he or she cannot aid in a delivery, unless a midwife sits nearby to oversee the process.

THESE days, mothers like Lilia Angcog can give birth for only P500. [photo by Avie Olarte]

The result of such legislation has been practically no maternal death in Carmen’s 29 barangays in the last five years, save for one in 2006. According to Dr. Josephine Jabonillo, Carmen’s municipal health officer (MHO), that unfortunate mother-to-be tried to deliver at home, with her father-in-law as the hilot. The father-in-law turned out to be untrained; the woman hemorrhaged to death.

“Most maternal deaths can be prevented,” says Jabonillo, an obstetrician/gynecologist. “Mothers all over the world die due to the same major complications of pregnancy: hemorrhage, hypertension, sepsis, and unsafe abortion.”

Globally, women continue to die due to complications of pregnancy and childbirth at a rate of one per minute. The limited progress in making motherhood safer is more alarming in developing countries, where 99 percent of maternal deaths occur every year. Here in the Philippines, about 10 to 12 women die every day due to pregnancy-related causes. The government has even admitted that it may not meet its commitment to achieve Millennium Development Goal (MDG) Number 5 — to drastically reduce the number of maternal deaths — by 2015.

And yet here is this town of 41,519 people that has been demonstrating just how far better local governments can be at keeping mothers healthy. Aside from its innovative laws regarding maternal health, Carmen also has what it calls the Enhanced Safe Motherhood Program (E-SM), which not only pushes for a RHU-based delivery, but also includes a pre-natal assessment, monthly check-ups, access to medicines, and other maternal health services — all for a nominal fee.

Location map of Carmen, Bohol courtesy of Wikipedia

TO FULLY appreciate what Carmen has accomplished so far, consider this: as late as 2005, the proportion of births attended by skilled health workers nationwide stood at 63.7 percent. In 2006, meanwhile, the national maternal mortality rate — the number of deaths per 100,000 live births — was 162. To be considered as having met MDG No. 5, the Philippines has to have all births attended by skilled health workers by 2015, as well as have reduced the maternal mortality rate to 52.3.

This predominantly agricultural town with more than half of its people living under the poverty line has managed to best those numbers — and how.

Yet even up close, there seems to be nothing that can make Carmen stand out among other rural towns across the Philippines. There are the small town center that passes for its urban area and a collection of dusty barangays. There are some cars and jeepneys and a lot of motorcycles. And just like any other Philippine town, there are children — lots of them — scampering about in the streets.

Then again, there is that birthing center, a 10-bedroom facility that is complete with delivery tables and laboratory equipment and can top the services of any hospital in this province some 800 kms south of Manila. Completed in 2006, it won a Sentrong Sigla Award (Center for Vitality) the very next year. According to the Department of Health (DOH), it is one the best rural health units in the country.

Building a good facility was on top of Jabonillo’s list when she became the town’s health officer in 2002. But she says it was no easy task, recalling that she had to first lobby hard with the local government officials.

“Carmen at the time had a very high record of maternal death,” Jabonillo recounts, “So I told the mayor we had to address it.”

Although the E-SM was Jabonillo’s idea, the local health board (headed by the mayor, and with Jabonillo, a councilor, and a nongovernmental organization representative as members) helped craft the program.

For the past five years, Carmen has had no maternal deaths except for one in 2006. Credit that to its award-winning rural health unit, which is complete with bedrooms, delivery tables, and laboratory facilities. [photo by Avie Olarte]

Jabonillo says that the town records revealed that the maternal deaths in Carmen were often caused by unhygienic and improper birth delivery practices. She also noted that there were also few skilled birth attendants, while women barely had access to pre-assessed normal delivery from the provincial hospitals.

These days, aside from the main one in the town center, five of Carmen’s barangays have birthing facilities. There are no doctors in these centers, but a midwife is usually on call, along with an army of barangay health workers; should any complications arise, an ambulance (Carmen has six) can be dispatched to bring the pregnant woman to the RHU.

But convincing the women to try the services of these clinics proved difficult. For one, the women thought they would be charged high rates. For another, they were simply more used to the hilot, some of whom even discouraged the pregnant women from going to the RHU. (This is, after all, a country where half of births still occur at home, and a third assisted by hilots. In Bohol, 17 percent of all the births in 2006 were aided by trained and untrained hilots, most or 53 percent are assisted by midwives.)

On E-SM’s first year, the RHU had a total of only eight deliveries. But by 2006, which was also the year the council passed the ordinance banning trained hilot from delivering babies, about 400 women ended up giving birth in the town facility.

“Maternal and birth complications were reduced to 50 percent,” Jabonillo says, leading to Carmen’s near-zero maternal death record.

AT VALLEHERMOSO, one of the barangays with a birthing center, the barangay midwife keeps track of all the pregnancies in the area. The health unit has on its white wall a pregnancy watch board that lists the names of pregnant women, together with the estimated date of confinement, last menstrual period, place and (estimated) date of delivery. There are also free pre-natal check-ups and some medicines, like iron tablets (many of Carmen’s women are anemic), are free as well.

Lilia Ancog’s barangay has no birthing center yet, so when time came for her to deliver her third child, she went to the main birthing center in town. Even then, she says her total bill came to only P500, or about 25 percent of the cost of a hospital-based delivery. She says that with her two older children, she had paid double that amount, and those deliveries were even done at home through a midwife.

“(It’s) high quality obstetric services at very reasonable amount,” says Jabonillo, who does not charge a doctor’s fee for the deliveries she does.

The doctor says that all the birthing center’s proceeds go to buying medicine and supplies like gloves and cotton, on top of the P1-million worth of drugs that the local government allocates for the RHU every year.

A patient in Carmen can even end up not paying anything at all. Last September, Carmen came up with a program for indigents with the government-run Philippine Health Insurance Corp. Through the program, a patient can avail of the Maternity Care Package that covers the first three deliveries, newborn screening, laboratory works, accommodation, medicine, and the P500 user’s fee.

VALLEHERMOSO remains one of the most densely populated barangays in Carmen. More than half of its population live below the poverty line. [photo by Avie Olarte]

That’s not all: Carmen is also one of only three towns in Bohol that have adopted a Reproductive Health Care Code; Bohol province itself has yet to pass one.

Carmen’s code mandates, among others, that women must have access to safe and quality reproductive healthcare services and that there should be a continuous planning, implementation, and monitoring of effective reproductive-health programs.

The code also ensures a steady stream of funding for reproductive health services, on top of the P50,000 allocated for the reproductive health advocacy program. A look at the town’s spending pattern shows that it allots an average of nine percent every year for health services compared to an average of four percent for infrastructure. (In most towns in Bohol, as in many local governments, building roads and bridges is prioritized over health and social services.)

For sure, though, the code has its critics. Some church workers have called its proponents “devils” and even launched a radio program to discredit the local officials pushing for it. One official who suffered such a backlash is Nathaniel Binlod, a two-term town councilor and chairperson of the town’s health committee. He almost lost in the 2007 elections, he says, for openly advocating and raising awareness on reproductive health and population management.

“I’m not for abortion,” says Binlod, who was born and raised in Carmen. “What I’m campaigning for is responsible parenthood. Two to three children are enough.” (The average family size in Carmen at present is 5.3.)

ACCESS TO reproductive-health services in Carmen comes in the form of making contraceptives available to the public. Together with the United Nations Population Fund (UNFPA) — with which it has partnered for such things as the ambulances and setting up barangay birthing centers — the town has built a Pop Shop that sells condom and pills at lower prices than those at retail stores.

HEALTH workers keep track of the condition of pregnant women in Vallehermoso. [photo by Avie Olarte]

The RHU itself allots P50,000 to P75,000 a year for buying contraceptives alone. The award-winning facility even has a Family Planning Room where couples can consult with a doctor regarding which family planning method would be best for them.

More Pop Shops are already being put up in the barangays. But women like Beatriz Manda, a 44-year-old mother from Vallehermoso, are unlikely to step foot into one unless they visit a local health unit first.

Manda says the natural way doesn’t work for her and her husband, because she has irregular periods. They already have 11 children, with the youngest only five months old.

But it may take some doing before she and her husband consider artificial family planning methods. “I’m afraid of the IUD (intrauterine device),” says Manda. “My husband meanwhile doesn’t like the condom, he says it might slip off.”

Someone also told her that once she has had a ligation, she wouldn’t be able to help her husband in the farm anymore.

Manda confesses that she has not paid a visit to the barangay’s midwife, who could help clarify common misconceptions on artificial family planning methods. But she says she is planning to go one of these days.

CONDOMS and birth-control pills can be bought for a cheaper price at Popshops. [photo by Avie Olarte]

If she opts to go to the RHU, she may just bump into Lilia Ancog, the mother who just gave birth there. Ancog is planning to visit the town doctor again as soon as she has had a few days of rest. She says she and her husband need a family-planning method aside from the natural way, which doesn’t seem to work for them. Her husband wants a fourth child, but Ancog says they can afford only three.

As for Jesusa Panes — the pregnant woman who with her drunken hilot walked all the way from her home to the barangay health center — she reached the place in one piece, the baby still safe in her tummy. And while she was sweating profusely when she arrived and was visibly worried that she would give birth any minute, she seemed to calm down somewhat after she downed a glass of spring water. As people fanned her, Panes politely declined offers to bring her to the nearest hospital, saying the midwife would take good care of her.

She later gave birth to a baby girl, her fourth child. Mother and newborn daughter are doing fine.