A mother in the town of Mansalay, Oriental Mindoro who belongs to the Mangyan tribe recalled how her husband had to pay a penalty at the municipal hall so that he could get their child’s registration of live birth. Meanwhile, another mother in the hinterlands of Eastern Samar had to borrow money to rent a house for a month in the town proper so that she could comply with the government’s policy of giving birth in a health facility.
There are 221 mothers out of 100,000 livebirths who die of childbirth and its complications. This is the worst performance since 1990 when the government targeted lowering maternal deaths to 52 by 2015. According to the Aquino government, home birthing is the cause of high maternal deaths, hence the Maternal, Newborn and Child Health and Nutrition Strategy (MNCHN), dubbed as the “No Home Birthing” Policy.
The policy mandates public facilities or local government units (LGUs) to generate income to upgrade birthing facilities or otherwise enter into public-private partnerships or accredit private facilities as Basic Emergency Obstetric and Newborn Care (BEmONC). Essentially, it pushes mothers to give birth in private or privatized facilities while public providers remain ill-equipped if not totally absent. The MNCHN manual of operations is backed by neoliberal advocates such as the World Bank, the US Agency for International Development and the Japan International Cooperation Agency.
The “no home birthing” policy has revealed itself to be burdensome and even dangerous, punitive and costly for the majority of Filipino mothers.
The Department of Health (DOH) has denied the existence of a “No Home Birthing Policy” time and again. Instead, DOH officials claim that the government is “merely advocating and encouraging facility-based deliveries”. The MNCHN strategy was first articulated through Administrative Order 2008-0029 under President Arroyo and updated under President Aquino through the MNCHN Manual of Operations (MOP) released in 2011. The MOP is clear on the prohibition of the traditional birth attendant (TBA)-assisted delivery (even by those trained by the government) and the promotion of facility-based delivery.
The “no home birthing” policy does not take into consideration that the chronic problems of the country’s health system is due to long-standing government neglect. This translates to not funding government hospitals, not hiring sufficient health personnel, and focusing on the curative rather than the preventive services. It also means prioritizing health insurance, which transfers the responsibility of health financing from the government to the individual. The policy has been implemented for almost seven years now, but maternal mortality has worsened and child mortality remains high amid privatized health services.
The Philippine health system chronically lacks government health professionals especially those at the forefront of public health services. There is barely one government doctor for every 100,000 population. There are only two midwives and not even one nurse per 10,000 population. A “no home birthing” policy is a turnaround from government’s previous program of TBAs in order to equip them with the correct skills for home delivery especially in the rural areas and to augment the shortage of midwives and nurses. With a “no home birthing” policy, the government recalled their birthing kits and prohibited them from practicing. Worse, the government relegated them the role that will earn personal incentives for every referral they give to the health facility.
The lack of health facilities also plagues mothers, especially in but not limited to rural areas. In 2013, out of 1,490 municipalities and 144 cities, only 981 municipalities and cities have accredited maternity care facilities. BEmONC and Comprehensive Emergency Obstetric and Newborn Care (CEmONC) centers are located in more urbanized areas.
Transportation is a related challenge, with many areas in the country not having means of public transportation. The distance to health facilities discourages those living in the interior and/or upland barangays from seeking services. Mothers from villages in remote and interior areas have difficulty going to health facilities usually located in the town centers. In Barangay Osmeña, General MacArthur, Eastern Samar, for instance, pregnant women who are near their term are transported to the health facility using a big woven basket (bikat) slung on the back. They have to go down to the town center two weeks or a month before they are due. They have to rent a space for some members of the family to live in while they are in the town center, but many of them cannot afford to maintain two households at the same time. In the province of Oriental Mindoro, indigenous Mangyans have to travel up to seven hours just to get to a health facility. They also have to endure discrimination while taking public transportation as many of the public utility vans do not want to take them as passengers. In the town of Cauayan, Negros Occidental, some midwives assist delivery not in BEmONC but in the ill-equipped barangay health station just so it can be reported that it is a facility-based delivery.
The “no home birthing” policy relies on punishing women and the poor to ensure compliance. Without ample public consultation, the policy is merely announced to midwives and barangay health workers (BHWs) who are then tasked to relay it to the communities. But the ordinances passed by the LGUs to adopt the MNCHN strategy have penalty clauses to ensure compliance. Penalties can be levied on the mother, the TBA, the companion during birthing or the midwife. A penalty clause usually carries an imprisonment or monetary penalty on health personnel or the traditional birth attendant who assists delivery at home. It can also be a monetary fine on the husband or assisting relatives or the denial of registration of birth.
These violate women’s and children’s right on several levels. In the town of Juban, Sorsogon, the municipal ordinance organized a maternal death investigation team composed of the Municipal Health Office, the local police, and the Municipal Social Welfare Office, that is authorized to give a warning on the first offense and impose a fine of Php30,000 for the second offense. In the town of Batad, Iloilo, there is a penalty of Php500 for the first offense if a TBA was found to have assisted a delivery. In the town of Bulalacao, Oriental Mindoro, a father was fined Php2,500 because his wife delivered at home while a mother who gave birth at home in the town of Bongabong had to pay Php1,500.
A “no home birthing” policy is not culturally acceptable to indigenous groups that practice their traditional home birthing. For example, Mangyans have a traditional way of giving birth, which is done in a squat position with the pregnant woman holding on to a rope tied to the ceiling. The husband or a companion can assist her by holding her torso while she holds on to the rope. Then they cut the umbilical cord with a blade from a plant called bagacay, a local species of bamboo. But now some of the Mangyan women are afraid of giving birth at home, because health workers from the health center say that if something happens to the newborn or to the mother, a case will be filed against those who assisted in the delivery. This is implemented more stringently to members of the poverty program, Pantawid Pamilyang Pilipino Program (4Ps) and the Conditional Cash Transfer (CCT), who were informed that they would not receive their cash grant if they do not give birth in a health facility.
The cost of giving birth in a health facility, even if it is public or government-run, is prohibitive.The use of a rural health unit (RHU) birthing facility costs from Php1,000 to Php3,500. Birthing expenses in a government hospital can be higher. Even PhilHealth members who are supposed to be covered by a maternity and neonatal care package have to prepare this amount when they go to a government hospital. Some mothers even pay a separate amount for the newborn screening even if PhilHealth supposedly covers this. Mothers try to save up for facility-based delivery, but the little amount that they save goes to emergency household expenses and is usually depleted at the time of delivery.
High user fees have discouraged mothers from giving birth in health facilities and increased the phenomenon of unexpectedly giving birth at home or in public places or vehicles. Results of the IBON maternal and child health and nutrition survey reveal that 43.3% of mothers surveyed gave birth at home, in a tricycle, in kuligligs (farm hand tractor), and other means of transportation or other places. Interestingly, 22.6% of mothers who did not give birth in a health facility said that the reason for not giving birth in a health facility is “sa bahay na inabutan” (inadvertently gave birth at home).
This corroborates the 2013 National Demographic and Health Survey (NDHS) report that only 4% of women who gave birth in the five years preceding the survey delivered free of charge or paid in kind. The average payment during their last live birth was Php2,982.00. There was not a big difference in the amount paid by women in urban and rural areas.
There is a wide difference in the rich and poor’s access to the services of a skilled health provider. According to the 2013 NDHS, almost 100% of live births of mothers belonging to the highest quintile was delivered by a skilled provider while only four out of 10 live births of mothers belonging to the poorest quintile were assisted by a skilled provider. The proportion of live births delivered by a skilled provider is also higher in urban areas.
PhilHealth, the government social health insurance program, has been touted by the Aquino government as the solution to high out of pocket payments. However it only paid 11% of total health expenditures and insurance coverage is low. The 2013 NDHS revealed that four out of 10 women (15-49 years old) do not have any type of health insurance.
Burden on poor women
The “no home birthing” policy exacerbates the already alarming health conditions in the country and burdens the poor women more. The root causes of maternal deaths and poor maternal health are the pervasive and entrenched poverty and inequality in the country. But government refuses to recognize nor address this. Instead, it has made the situation worse by implementing neoliberal health privatization policies that make the availability of health services dependent on one’s capacity to pay.
(This article is based on the book Critical Condition: Privatized Health in the Philippines,which features IBON’s research on maternal and child health and nutrition conducted in seven provinces and one city in Metro Manila in 2014.)