Are home births being banned?

Ana P. Santos
Facility-based deliveries may be the gold standard for healthcare but the reality on the ground necessitates flexibility in our healthcare policy

EXPERT CARE. Facility-based deliveries are seen as a crucial to lowering maternal mortality ratio. All photos by Ana Santos/Rappler

MANILA, Philippines – May Galvez Arzaga has been working as a licensed midwife (also known as a skilled birth attendant or SBA) in Puerto Princesa, Palawan for six years now. She can no longer count how many mothers she has assisted and how many babies she has delivered in those six years.

Lately though, the number of pregnant women requesting her birthing assistance has been on the decline.  

“Dapat daw kasi sa birthing facility o di kaya sa hospital na manganak,” said Arzaga. (We’ve been hearing that births now have to take place in a birthing facility or in a hospital.)

Arzaga says that the prohibition on home births is coming from the local municipal health office, but she is not entirely sure. 

Another resident of Puerto Princesa, Cristina Magalona, shared that she has also heard that home births are now banned. Her source is her mother, who is a local hilot or traditional birth attendant (TBA). 

Her mother delivered seven of Magalona’s eight children in her home. “Pero bawal na daw ngayon, sabi ni Nanay. Ico-confiscate daw ang mga gamit pag nagpaanak sa bahay.” (But my mother told me that home births are now prohibited. Her equipment like her scissors and forceps will be confiscated.) 

Among midwives, hilots and health experts, there is confusion about the Department of Health’s (DOH) stance on homebirths and if the DOH is prohibiting them in an effort to curb the country’s maternal mortality ratio (MMR) which has remained stagnant.

Health experts have already predicted that the Philippines would not be able to meet its Millennium Development Goal of reducing MMR to 55 deaths per 100,000 live births by 2015.

HOME CARE. More than half of all births in the Philippines take place at home under the supervision of a traditional birth attendant known locally as a hilot 

Facility-based delivery

In an attempt to curb MMR, the DOH—under President Gloria Macapagal-Arroyo—passed Administrative Order 2008-0029 titled, “Implementing Health Reforms towards Rapid Reduction in Maternal and Neonatal Mortality,” or the “No Home Birthing Policy.”

Data from the Family Health Survey (FHS) of 2011 shows that 60 percent of births take place at home under the care of a TBA or hilot, who does not possess adequate medical training to facilitate child delivery.

Advocating facility-based deliveries where women can get timely and correct diagnosis, early intervention, and access to emergency obstetric care under the supervision of a licensed SBA or doctor is considered to be a crucial factor in lowering MMR.

In 2011, the DOH updated the policy, called The Maternal, Newborn, Child Health and Nutrition (MNCHN) Strategy.

Under the devolved health system, which was implanted in 1991, the management of and delivery of health services was transferred from the central agency to local government units (LGU).

The devolution was designed for the faster implementation of national health policies and for LGUs to customize programs based on their area’s cultural nuances and context. However, varied interpretation has made for varied implementation of health policies like the MNCHN.

In the province of Samar, Dr. Samuel Baldono, a municipal health officer, said they provide an incentive of P300-P500 to the TBA for referring and accompanying the woman to the health facility where she can have her baby delivered at no cost to her.

“We have seen a dramatic increase in facility-based delivery since this incentive was put in place and a corresponding decrease in maternal death. For the past two years, facility-based delivery has risen to about 89 percent and we have had zero maternal deaths,” said Baldono.

However, some municipalities have reportedly implemented punitive measures  punishing either the mother or the TBA for pursuing a home birth.

In Sultan Kudirat, a birthing policy pushing for facility-based deliveries was passed. Violations of this policy are meted a fine of P2,000.

“There was a lot of protest, so the fine was never implemented, but the provision is there,” said Renan Kasan, a United Nations Population Fund Area Program Officer (UNFPA-APO).

Other similar punitive measures have been reported in other areas. In Quezon City, City Ordinance No. 2171 “prohibits home births in Quezon City, prohibits traditional birth attendants to deliver babies and requires all professional health practitioners to deliver babies only in health facilities.” A fine of P5,000 will be imposed for any violation of this ordinance.

In some other areas, like Palawan, the actual provisions remain ambiguous.

MOTHER'S CHOICE. There is some confusion as to what the exact policy of the Department of Health (DOH) is with regards to home birthing 

Ami Evangelista Swanepol, executive director of Roots of Health, a Puerto Princesa-based NGO which provides reproductive health (RH) services said, “According to our clinical staff, home births are now prohibited because there are high incidences of maternal mortality and infant death, so much better to give birth in a hospital. Every time they heard it was prohibited, it was always that birthing at home was prohibited—not just birthing at home with a hilot was prohibited—so they thought this applied to them as well.”

“While they have not heard of anyone actually being punished for attending a home birth, they fear that if they do [assist a home birth] and something bad happens, they would lose their licenses or have cases brought against them,” added Evangelista Swanepol.

According to Evangelista Swanepol, while giving birth in a facility is better, it is not always possible because the woman is scared of giving birth in a hospital or simply does not have the money to do so.

A normal delivery at the Dr. Fabella Memorial Hospital, the maternal and newborn tertiary hospital in Manila, is estimated to cost between P3,000 to P5,000.

Dr. Honorata Catibog, director for the DOH Family Health Office, said, “It is clear that having births in a healthcare facility under a skilled birth attendant is critical in ensuring the health and safety of both the mother and her baby and thus, lowering maternal death. Facility-based delivery is the gold standard.”

However, Catibog clarified, “There is no such thing as a ban on home births. We know the realities. Given our geography and resources, it is not realistic. We are simply advocating and encouraging facility-based deliveries.”

Cultural barriers

“We have to break down a lot of cultural barriers [to transition from home births to facility],” said Dr. Junice Melgar, executive director of Likhaan Center for Women’s Health.

“Some community women are simply not comfortable giving birth in a hospital. They have experienced, or are afraid of being looked down on, by some haughty health care professionals. The hilot provides a personal service like massaging her, cleaning up her house or looking after her children after she has just given birth. A doctor or a midwife will not be able to do that,” said Melgar.

Melgar also said that the current health care infrastructure is not capacitized to take on the estimated 2 million births that occur every year.

“Perhaps a better solution is to allow midwives to make house calls and home deliveries. For low risk pregnancies, this is done even in developed countries. However, we need to provide the midwife with additional support like transportation and communication so she can refer a case to a nearest facility in case of an emergency,” Melgar concluded. – Rappler.com

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