The last day of this field visit began in Alabel, Sarangani at the Municipal Health Office. This was a courtesy call to introduce and discuss the Maternal Health & Nutrition program with Municipal Mayor, Hon Corazon Grafilo, followed by courtesy calls and meetings with the Provincial and Municipal Health Officers.
The Alabel birthing home has 40-50 deliveries a month, mostly women with PhilHealth insurance and enrolled on the 4P’s program. The Municipal Health Officer explained that the majority of births here are still at home, attended by a Hilot or midwife. There is a great need to target the vulnerable population in the conflict areas as well as the geographically difficult parts (GIDA’s – Geographically Isolated and Depressed Areas).
The birth plan for preparing pregnant women for complications or unexpected adverse events during pregnancy, childbirth or the early post natal period is encouraged but not used – there is little motivation because transport is expensive and the roads are poor, although there is an intention to expand services to provide an ambulance. With limited transport allowances for field workers in far flung areas, support and education for women remains limited.
One of the biggest challenges is the lack of physicians, particularly as they also do activities for the municipal health office. We talked about the need for a halfway home near a birthing facility where mothers can wait nearer to delivery and how this may be resourced.
The Provincial Health Officer also confirms that facility based deliveries are low and explains the weaknesses in the midwife services, created by financial inequalities. This will require national recommendations to resolve rather than be under the control of the local governments. Recruitment and retention of Barangay Health Workers remains a consistent problem and needs to be strengthened. Every 3 years the Barangay chairperson is replaced – the newly elected chairperson will want their own BHW’s so there is no association with their predecessor, but resulting in a loss of continuity of BHW knowledge and skills.
Physicians do not visit communities to check the Mother and Child books or birth plans which can identify high risk patients, nor see that respectful maternal care is being delivered or learn where improvements might be needed. Gone are the days he says, where midwives go to houses to check for pregnancies and give information.
Similarly, when asked about the use of the birth plan he estimates about 10% are implemented – mothers are usually told that they need to have their baby at a facility as required by law, but is unlikely to be implemented with their subsequent pregnancies.
Our next stop was to Notre Dame of Dadiangas University (NDDU) to discuss the preliminary findings of the MNCHN Situational Analysis. This was conducted by a team of nurses in 2 municipalities in the Sarangani provinces Maitum and Malungon and will ensure Save can establish resources, avoid duplication with other ongoing projects and discover what is really needed for the new program. Here is a brief summary of their findings:
- Gender inequality: Fathers are not attending mother and child classes as they feel too embarrassed to attend, but say they are willing to attend if programs were announced earlier. This would enable them to plan financially (time off work) and would be keen to comply. The worst thing they say about being a father is not knowing how to take care of their wife and baby from a maternal and child health perspective and have little knowledge about what goes on. Grandmothers serve as advisors, mothers are the primary care providers for infants and children, husbands are primed to provide financial support.
- Services: Facility based deliveries are driven by economic incentives i.e. mothers receive 500 pesos in PhilHealth benefits, although not all have a full understanding of the benefits, rather an apprehension about the imposed sanctions.
- Basic maternal and child care services are available and delivered by qualified personnel, however quality of services maybe inadequate due to increased seasonal demands e.g. illnesses in the community, lack of medicines and the inability to afford them.
- The main concerns from mothers in the highlands are distance; who will cover expenses and where they will stay.
- Breast feeding practices: Factors affecting the advocacy of breastfeeding include mostly economics, rarely health benefits. The Islamic community’s feeding practices include discarding the colostrum believing it to be dirty/unhygienic and bad for the baby. Elders influence these beliefs and practices.
- Community: Family planning is non-existent in the Islamaic communities – pregnancies are considered a blessing from god. Some women take the pill but do not tell their husbands. There is a need to engage and bring on board the Imams and community leaders.
- Young mothers are often not aware that they are pregnant due to lack of education in school, or are in fear/denial.
- Women control the decisions about their pregnancy, but elders/significant kin act as educators and sources of support. There is good trust between the community and midwives/BHW’s, however cultural practices which are very strong are passed down.
- There is no accurate data in the highland communities regarding maternal health and mortality, only anecdotal evidence. Husbands sometimes deliver babies and conceal mortalities because of sanctions. Deaths in the Islamic communities need to be buried within 24hrs and there is an unwillingness to talk. The inability to access dangerous regions e.g. areas occupied by NPA (New People’s Army) means that acquiring and validating the accuracy of data becomes impossible.
These were fascinating insights stimulating discussion and ideas. It’s been an amazing week in the field, seeing the challenges first hand. It was extremely sad to learn about the death of the preterm baby we saw being delivered, highlighting the reality of the situation here and exposing the gaps. Yet we also came away with many positives such as the great efforts being made in trying to address them. One such high point rounded off day 3 with a visit to a High school in Maitum.
Here, Teen Facilitators’ training was being conducted by the AD-ASRH Project Officer (Adolescent Sexual and Reproductive Health – Adolescent Development Program), Anne Marie Mejicano.
We were greeted by a chorus of jubilant singing welcoming us to the session. It was fabulous! As I observed the informal interview-discussions with the Teen facilitators, Doc Aidee, Doc Mads & the adolescents in the program, Doc Mads then turned to me and said “They want to hear you speak”. Silently panicking, I asked “What do they want to hear?” which triggered a blast of teenage screams!
I was startled their reaction feeling momentarily like a one of the Beatles. So I stood up and talked about a bit about myself and why I was in the Philippines (and how much I was enjoying it!) but also about the importance of education and discovered there may be some future dr’s and nurses, among other professions, in the audience. Their energy and enthusiasm was infectious and as I walked (on air) back to our van, I remember thinking what a bright future the Philippines has with this inspiring young generation.
Next stop…Barangay bingo, beauty pageants and microphobia. Speak soon, Alli 🙂