Adopted: 11 May 2015
Date Filed: 14 May 2015
I. Background

The Philippines is signatory to the United Nations Millennium Declaration that defined 8 development goals 3 of which relates directly to health. The Millennium Development Goals (MDGs) are for countries of the world to accomplish in a span of 15 years to ensure the attainment of better quality of life for its people. In health, emphasis has been heavily placed on accelerating improvements in the attainment of MDGs 4 and 5 that aim to reduce under-five child and maternal mortality by 2015. Beyond 2015, the global target is an MMR of less than 70 by 2030; for the country the aim is to reduce maternal mortality ratio to 39.

To guide program implementers and service providers, the Department of Health, issued 2 administrative orders aimed at making pregnancy and delivery safer for both the mother and child: 1) AO 79, s. 2000 also known as the Safe Motherhood Policy issued in July 2000 and 2) AO 2008-0029 on Implementing Health Reforms to Rapidly Reduce Maternal and Neonatal Mortality in 9 September 2008. This is known as the MNCHN Policy. Both issuances target a reduction in maternal and newborn mortality.

Studies and experiences of other countries that have drastically reduced their maternal mortalities have shown that although women and the unborn need care, attention during delivery is most important to guarantee better survival of the mother and her newborn. In the Philippines 73% of births are attended by skilled health professionals and 61% occur at a health facility (NDHS 2013). But while there are improvements in maternal health outcomes, maternal mortality ratio remain high at 221/100,000 live births (FHS 2011) and 130/100,000 live births (UN Estimate, 2013). There is thus a need to further the delivery of basic emergency obstetrics and newborn care at the periphery. These services shall include among others the administration of life saving drugs by nurses and midwives in circumstances where a referral doctor or facility is not available.

II. Objective

This Guideline mandates the health sector to strengthen the capacity of nurses and midwives in maternal and newborn care to adequately and appropriately respond to pregnancy-related complications by ensuring that they are trained on Basic Emergency Obstetric and Newborn Care (BEmONC) and other related training courses and allowing them to perform all the BEmONC signal functions as defined by the Department of Health including the administration of life saving drugs as mandated by Republic Act 10354 (RPRH Act of 2012).

This AO likewise mandates every nurse and midwife practitioner to administer life-saving drugs such as but not limited to oxytocin, anticonvulsants, corticosteroids, and antibiotics in emergency situations and where there are no available doctor and health facility.

III. Scope and Coverage

This Order shall apply to all heads of health facilities providing birthing services as well as registered nurses and midwives that provide skilled health professional maternal and newborn care services in both the public and private health sector.

IV. General Principles

To ensure safer pregnancy and delivery, the following principles shall guide every policy maker, program manager, local chief executive, health officer and health care provider in maternal and newborn health:

1. For better health outcomes, every pregnancy shall be planned and supported.
   
2. Health care providers shall perform the highest quality of care possible to ensure safety in every delivery.
   
3. Gender and culture sensitivity shall be the norm in health service provision.
   
4. A three-pronged approach that comprise the following shall be adopted:
   
   
   1. Birthing Centers upgraded to perform emergency obstetric and newborn care;
      
   2. Health Professionals trained to proficiency in the performance of basic emergency obstetric and newborn care; and
      
   3. Reproductive health services made universally accessible to persons of reproductive age.
   
   
5. Every woman shall be encouraged to give birth in a health facility.
   
6. System-wide approach shall be implemented to ensure a wide reach.
   
7. Every client shall be accorded the right to make free and informed decisions in matters related to one ™s health.

V. Definition of Terms

1. Basic Emergency Obstetric and Newborn Care (BEmONC) refers to lifesaving services for emergency maternal and newborn conditions/ complications being provided by a health facility or professional to include the following services: administration of parenteral oxytocic drugs, administration of loading dose of parenteral anticonvulsants, administration of loading dose of parenteral antibiotics, antenatal administration of loading dose of steroids in threatened premature delivery, performance of assisted vaginal deliveries, removal of retained placental products, and manual removal of retained placenta. It also includes neonatal interventions which include at the minimum: newborn resuscitation, provision of warmth, referral and blood transfusion where possible.
   
2. Skilled Health Professional refers to a doctor, nurse and midwife who has been educated and trained in the skills needed to manage normal and complicated pregnancies, childbirth and the immediate postnatal period, and in the identification, management and referral of complications in women and newborns.
   
   
   • Midwife is a professional trained to provide services that require an understanding of the principles and application of procedures and techniques in the supervision and care of women during pregnancy, labor and puerperium, management of normal deliveries, including performance of internal examination during labor except when patient is with antenatal bleeding, carry out written order of the physician with regard to antenatal, intra-natal and postnatal care of the normal pregnant including giving of immunization, oral and parenteral dispensing of oxytocic drug, suturing perineal laceration, give intravenous fluid during obstetrical emergencies provided she has been trained for that purpose and may inject vitamin K to newborns.
     
   • Nurse is a duly registered professional who has successfully completed training in a formal nursing education program and has acquired knowledge and skills in health promotion and maintenance, disease prevention, physical and psychosocial assessment and management of health and illness for women throughout their life cycle. As a member of the BEmONC Team, the nurse provides independent and collaborative functions under the direct and indirect supervision of a physician in the provision of preventive care, episodic care, collaborative care and surgical care.
     
   
   
3. Life Saving Drugs are drugs such as oxytocin, magnesium sulfate, antenatal steroids, and antibiotics, among other medicines used to prevent and manage pregnancy-related complications.
   
4. For purposes of this Administrative Order, Emergency shall be defined as a condition or state of a patient wherein based on the objective findings of a prudent medical officer, nurse or midwife on duty for the day there is immediate danger and where delay in initial support and treatment may cause loss of life or cause permanent disability to the patient.

VI. Implementing Guidelines

RA 10354 otherwise known as the Responsible Parenthood and Reproductive Health Act of 2012 mandates nurses and midwives who are tasked to provide maternal and newborn care services to administer life-saving drugs such as but not limited to oxytocin, steroids, antibiotics and magnesium sulfate in accordance with the following conditions:

1. The patient is suffering from a complication evaluated to be an emergency as defined in this Order and no physician and health facility is available to manage such condition.
   
2. Nurses shall have completed the 11-day basic emergency obstetric and newborn care (BEmONC) skills training course and certified to perform the BEmONC signal functions required of nurses by a Training Center recognized by the Department of Health.
   
3. Midwives shall have completed the 11-day basic emergency obstetric and newborn care (BEmONC) skills training course or the 7-day BEmONC training for midwives and certified to perform the BEmONC signal functions required of midwives by a Training Center recognized by the Department of Health.
   
4. The BEmONC Skills Training Course shall include the administration of life saving drugs. Thus a nurse or midwife certified to perform the BEmONC signal functions as defined by the Department of Health is automatically certified to administer life saving drugs.
   
5. All emergency drugs to be administered by nurses and midwives shall be covered by a physician ™s order.
   
   
   • In cases where a written order is impossible to obtain such as when the physician is not physically available, a verbal order shall be acquired through a call and appropriately recorded by the nurse or midwife. The verbal order shall be read to the physician before ending the call for confirmation. As soon as the physician is physically available in the health facility, he or she shall be made to sign the verbal order made.
     
     
   • In areas where geographic isolation brought about by calamities or armed conflict are likely to occur any time and a written or verbal order is impossible to obtain, a clinical protocol duly signed by the physician shall be made available at the Birthing Center. Said protocol shall specify the following:
     
     

     >	Signs and symptoms of an emergency condition
     >	Drug to administer for such manifestations
     >	Timing and dosage of drug administration
     >	Route of drug administration
     >	Frequency of administration
     >	Signs and symptoms of an improving condition

   
   
6. The nurse or midwife shall inform the physician by all means about the administration of an emergency drug and apprise him or her of the patient ™s condition when or where possible. These actions shall be recorded in the Individual Treatment Chart/Patient ™s Chart.
   
7. All patients administered with an emergency drug shall be REFERRED IMMEDIATELY after the administration of the loading dose or as soon as the situation warrants, to the nearest facility providing comprehensive emergency obstetric and newborn care (CEmONC).
   
8. In the interest of saving patients ™ lives, nurses and midwives shall strictly observe the protocol for referral.
   
   
   • Emergency transport shall be available to the patient either for free or for a fee.
     
   • A health worker shall be available to accompany the patient to the referral hospital.
     
   • Relevant Patient ™s record should be with the patient at the time of referral for endorsement to the referral hospital.
     
   • Referral note that specifies reason for referral and specific actions and medical management received at the referring facility.
     
   • While the patient is in transit, a call to the referral facility shall be made by the referring health worker to inform the receiving officer at the referral facility of such referral.

VII. Roles and Responsibilities

A. Training Centers offering BEmONC Skills course shall:

1. Manage the Training Program and conduct BEmONC Skills Training to service providers: doctors, nurses and midwives from the public and private sector as well as members of the academe, such as but not limited to the faculty members of schools of midwifery and colleges of nursing.
   
2. Conduct a Post Training Evaluation (PTE) as required by the BEmONC Skills Training design and certify the trainee ™s ability to perform the BEmONC signal functions required according to the definition of the Department of Health.
   
3. Issue a Certificate of Training to each trainee upon completion of the course requirements that include but are not limited to the following: pretest, passing the post test and return - demonstrations other related learning experiences (RLEs) and Certificate of Competency upon passing the Post Training Evaluation.
   
4. Ensure that the course is in compliance with the Standards of Nursing and Midwifery in the Philippines, certify that the Training Course is accredited by the Professional Regulation Commission (PRC) Board of Nursing and Board of Midwifery.

B. Local Government Units through the Provincial, City and Municipal Health Offices shall:

1. Ensure that the operation of their Birthing Centers in both the public and private sector comply with the DOH licensing requirements and the accreditation requirements of PhilHealth.
   
2. Ensure that life-saving drugs are available in all Birthing Centers including private birthing centers at all times in adequate number based on case load and experience.
   
3. Allow their staff to attend training programs such as but not limited to the BEmONC skills training course by providing paid time, cost of travel and the allowable per diem.
   
4. Sponsor or source out sponsors for their staff training.
   
5. Implement this Order by translating into local policy for optimal compliance by critical stakeholders.
   
6. Engage local chapters of professional groups such as: The Philippine Obstetrical and Gynecological Society (POGS), The Philippine Pediatric Society (PPS), The Philippine Society for Newborn Medicine (PSNbM), Philippine Nurses Association (PNA), The Philippine League of Government Nurses and the various Midwives Association to assist the Local Health Board in ensuring the effective implementation of this Order.
   
7. Ensure the setting-up of an operational public-private service delivery network that defines an efficient referral system within and outside geographical boundaries.
   
8. Ensure that each Birthing Center, including private birthing centers, has a stand by emergency transport, which is either a properly maintained government ambulance or privately owned public conveyance.
   
9. Conduct periodic monitoring and supervision of birthing centers to ensure health workers ™ compliance to the standards of BEmONC including the provision of life saving drugs and assess quality of care.

C. Department of Health through the Disease Prevention and Control Bureau, Women and Men ™s Health Development Division shall:

1. Provide over-all supervision of the BEmONC Skills Training Program being implemented in recognized Training Centers in the country.
   
2. Ensure that related training protocols including its technical contents are updated.
   
3. The National Safe Motherhood Program shall collaborate with the DOH Regional Offices on the conduct of periodic monitoring of the implementation of this order through such activities as monitoring of Program indicators that reflect client and provider behavior change as well as quality of care.
   
4. Cause the expansion of Training Centers for BEmONC skills as necessary.
   
5. Allot funds for the sponsorship of trainees to the BEmONC skills course.

VIII. Monitoring and Evaluation

Monitoring and supervision of BEmONC teams as well as individually practicing professionals including nurses and midwives in the public and private health sector shall be conducted through a cooperative effort of the Provincial and City Health Offices and the DOH Regional Offices.

IX. Repealing Clause

The provision of previous Orders and other related Issuances that are inconsistent with this Administrative Order are hereby rescinded. All other provisions of existing issuances which are not affected by this Order shall remain valid and in effect.

X. Effectivity

This Order shall take effect immediately.

(SGD) JANETTE LORETO-GARIN, MD, MBA-H
Acting Secretary of Health