I. BACKGROUND

The Philippines is a signatory to the United Nations Millennium Development Goals (MDGs). Emphasis has been heavily placed on accelerating improvements in the attainment of the MDGs 4 and 5 that aim to reduce under-five children and maternal deaths all over the world by 2015.

In July 2000, the Department of Health issued Administrative Order No. 79, s. 2000 on Safe Motherhood Policy with the goal of ensuring safe motherhood and healthy newborns and reduction of maternal and perinatal morbidity and mortality. Likewise, Administrative Order 2008-0029 was issued on 09 September 2008 on implementing Health Reforms for Rapid Reduction of Maternal and Neonatal Mortality (MNCHN policy).

The 2006 Family Planning Survey (FPS) showed a slow decline of maternal deaths from 209 (1993, NDS) to 162 for every 100,000 live births (maternal mortality ratio). The World Health Organization (WHO), United Nations Population Fund (UNFPA) and the World Bank (WB) 2005 Joint Report estimated around 4,600 mothers die annually in the Philippines, with this MMR. The 2008 National Demographic and Health Survey (NDHS) showed infant mortality rate (IMR) at 25 deaths per 1000 live births. Neonates under 28 days old account for 57.9 percent of infants deaths, of which 46.1 percent of these were less than one week old. Newborn death is closely linked with maternal condition during delivery.

History and research have shown that although women and babies need pregnancy care, care in childbirth is the most important for the survival of the mother- newborn pair. One-third of births around the world, take place at home without the assistance of skilled birth attendance. In the Philippines, 38 percent of births are not attended by skilled birth attendants (SBAs) or skilled health workers^[1] and 58 percent of births are occurring at home (NDHS 2008). Commonly reported direct causes of maternal deaths in Philippine Health Statistics are hypertension (28.4%), post-partum hemorrhage (17.2%) and pregnancy with abortive outcome (8.3%). Among the neonates, the leading causes of deaths are asphyxia, sepsis and prematurity.

Life-saving drugs are locally available to immediately manage the above pregnancy-related complications. However, accessibility to these drugs and the proficiency of frontline health workers to administer them whenever they are needed, are wanting.

In this country, midwives are the frontline health providers of maternal and child care. They are everywhere and based on the recent count, there were approx. 18,000 midwives employed in the public sector while the rest are in various form of occupation.

Currently, there are limitations on the scope of functions midwives can do to address the leading causes of maternal and newborn deaths. These limitations can be mitigated by an enabling policy environment that will support and empower midwives to save the lives of mothers and newborns, who are entitled to their rights to life and the highest attainable standard to health.

There is wisdom in investing on capacity building of midwives so that they can better respond to the emergency situations through administration of these life-saving drugs, especially on hard-to-reach areas among the 42,000 villages where lives of mothers and newborns are at stake in the absence of doctors or referral facilities.

II. OBJECTIVE

To strengthen the capacity of midwives to adequately and appropriately respond to pregnancy-related complications and reduce maternal and newborn morbidity and mortalities through administration of life-saving drugs and medicines.

III. GENERAL PRINCIPLES

• Every pregnancy should be planned and supported

• Every delivery should be safe

•  Service delivery should be gender and culture-sensitive

• A three-pronged approach shall be utilized

• deliveries by skilled health personnel with a continuum of care approach

• easy access to emergency obstetric and newborn care

•  universal access to family planning and reproductive health services

• Facility-based deliveries are highly encouraged

• System-wide approaches shall be utilized
  

• Rights based approach shall be utilized

IV. DEFINITION OF TERMS

1. BEmONC - Basic Emergency Obstetric and Neonatal Care

2. E/EmONC - Essential and Emergency Obstetric and Neonatal Care

3. ENC protocol - Essential Newborn Care protocol

4. Midwife-persons who, having been regularly admitted to an educational programme duly recognized in the country in which it is located, having successfully completed the prescribed course of studies in midwifery and acquired the requisite qualifications, are registered and licensed to practice midwifery (WHO, ICM, FIGO).

5. Life-Saving Drugs are drugs and medicines used to prevent and manage pregnancy-related complications such as but not limited to Magnesium Sulphate, Oxytocin, Steroid and oral antibiotics.

6. Emergency conditions are conditions that put the mother and the newborn at risk of complications or dying if not timely prevented or managed. These include the following:

a. Pre-eclampsia - a condition specific to pregnancy, arising after the 20th week of gestation, characterized by hypertension and proteinuria.

b. Eclampsia - condition peculiar to pregnancy or newly delivered woman, characterized by convulsions followed by coma. The convulsions may occur in the antepartum, intrapartum or early postpartum periods.

c. Post-partum Hemorrhage - blood loss greater than 500ml or more from the genital tract after delivery.

d. Premature Labor - active contraction of the uterus before the 37^th completed week of pregnancy

e. Infections

V. SCOPE AND COVERAGE

This order shall apply to all registered/licensed midwives that provide skilled midwifery services and likewise intend to obtain Maternity Care Package (MCP) and Newborn Care Package (NCP) accreditations from PhilHealth, the whole hierarchy of DOH and its attached agencies, as well as LGUs, and other development partners implementing the MNCHN strategy.

VI. GENERAL GUIDELINES

Under this order and in addition to the existing functions defined in section 23 of the Midwifery Act of 1992, the midwives are hereby allowed to administer life saving drugs such as magnesium sulphate, oxytocin, steroids and oral antibiotics, provided they are appropriately trained and certified proficient to perform the necessary care and services to prevent maternal and newborn deaths.

These interventions are meant to be provided under emergency conditions when no physician is available.

VII. IMPLEMENTING GUIDELINES

1. All practicing midwives who intend to obtain accreditation as E/EmONC providers, shall undertake in-service training, which is two-part: formal/didactic and practicum, using the approved modules and other instructional materials that would upgrade their knowledge and skills on essential and emergency obstetrics and newborn care (E/EmONC);

2. A post training evaluation shall include written examination, practicum at the hospital training facilities and application of skills to their areas of work. The midwife must pass a post-training evaluation after formal part of the training before being allowed to undergo practicum. Certificate of proficiency shall be issued upon satisfactory completion of practicum within six months.

3. Every midwife should be supervised by the municipal, district, city or provincial health officer or senior midwife supervisors with the technical guidance of Philippine Obstetrical and Gynecological Society (POGS) for maternal care and with the Philippine Society of Newborn Medicine (PSNbM) and/or Philippine Pediatrics Society (PPS) members for newborn/neonatal care, wherever possible;

4. Midwives shall be provided with legal assistance, if this becomes necessary in relation to their performance as E/EmONC providers such as in administering life saving drugs.

5. The following life saving drugs should be in accordance with the clinical practice protocol: 

a. Magnesium sulphate (MgSO ) shall be used for the prevention and management of eclampsia.

b. Oxytocin shall be administered for active management of third stage of labor (AMTSL) and initial management of post-partum hemorrhage.

c. Steroids shall be administered in cases of preterm labor.

d. Antibiotics shall be administered in cases of infections.

VIII. ROLES AND RESPONSIBILITIES

A. POGS shall:

1. Conduct training of midwives in appropriate training institutions all over the country;

2. Issue proficiency certification to midwives they directly trained practicing in areas they covered;

3. Conduct monitoring, coaching, or field visits with other stakeholders to assist and provide advise to midwives in their field of assignment;

4. Conduct or participate in regular maternal death reviews in accordance with the Maternal Death Review (MDR) protocol;

5. In collaboration with Philippine Society for Newborn Medicine, Philippine Pediatric Society (PSNbM/PPS), and/or Perinatal Association of the Philippines, Inc. (PAPI), it shall conduct perinatal death review in accordance with the Perinatal Death Review (PDR) protocol.

B. PSNbM/PPS and/or PAPI shall:

1. Coordinate with POGS in the conduct of training of midwives especially in the areas of newborn care;

2. Coordinate with POGS in the conduct of monitoring, coaching or field visits with other stakeholders to assist and advise midwives on newborn care in their field of assignment;

3. Coordinate with POGS in the conduct of regular maternal and new born death reviews in accordance with the MDR and PDR protocol;

C. Midwives Associations shall:

1. Update their roster of members to ensure that all practicing, licensed midwives are appropriately trained on essential and emergency obstetrics and newborn care (E/EmONC);

2. Ensure proper representation in the conduct of Maternal and Perinatal mortality and morbidity reviews; and

3. Conduct monitoring and internal audit to ensure that all midwives adhere to standards, norms and quality assurance protocols;

D. LGUs shall:

1. Ensure that LGU midwives have the necessary and updated licenses to practice and provide LGU midwives financial support to undergo the training or capacity enhancement on E/EmONC;

2. Ensure that LGU facilities have adequate supplies, equipment, drugs and medicines at all times and develop the infrastructure to ensure utmost delivery of quality E/EmONC for all mothers and newborns;

3. Ensure that LGU-managed hospital facilities shall be accessible for the conduct of training, as well as maternal and perinatal death reviews.

4. Activate, sustain and expand the membership of the local health board to include representatives of local chapters of POGS, midwives association and PPS/PSNbM and/or PAPI to ensure effective implementation of this order;

5. Ensure enrolment of indigent families and PhilHealth MCP accreditation of all birthing facilities in their jurisdiction; and

6. Set-up a functional referral system and service delivery network utilizing both public and private health facilities and providers to ensure continuum of care.

E. DOH:

E.1 National Center for Disease Prevention and Control - provide technical assistance to CHDs and LGUs and ensure compliance to standards and protocols governing administration of life-saving drugs and medicines. It shall coordinate with Health Human Resource Development Bureau (HHRDB) in identifying training hospital facilities.

E.2 Health Human Resource Development Bureau - provide technical assistance and human resource support in the training and education of midwives.

E.3 Bureau of International Health Cooperation - ensure proper coordination of technical assistance from development partners in support of training, education and facility improvement;

E.4 DOH-Centers for Health Development (CHD) - provide technical assistance, monitoring and evaluation on the implementation of this order at the local level.

E.5 DOH-retained hospitals - serve as training facilities, and ensure access to clinical materials for the midwives who are undergoing training.

F. Development Partners - support implementation of this order through technical and financial assistance in training, research, education and facility enhancement needed to further this issuance.

IX. MONITORING AND EVALUATION

Quality assurance and clinical audit should be conducted at least once a month, by the DOH-CHDs ™ Local Health Support Division and its retained hospitals and progress report shall be submitted to the Office of the Secretary. An annual implementation review shall be done with the stakeholders.

X. REPEALING CLAUSE

The provisions of previous Orders and other related issuances inconsistent or contrary with the provisions of this Administrative Order are hereby revised, modified, repealed or rescinded accordingly. All other provisions of existing issuances which are not affected by this Order shall remain valid and in effect.

XI. EFFECTIVITY

This Order shall take effect immediately 15 days after publication in major newspapers.

(SGD.) ESPERANZA I. CABRAL, MD
  Secretary of Health

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^[1] SBA/SHW - an accredited health professional (a midwife, doctor or nurse) who had been educated and trained to proficiency in the skills needed to manage normal (uncomplicated) pregnancies, childbirth and the immediate postnatal period and in the identification, management and referral of complications in women and newborns (WHO 2004).