PEOPLE COUNT P L C P D P O L
Philippine Government Policies in Reducing
Maternal Mortality By Carlos O. Tulali
Overview
Since the late 1980s, improving maternal health and
reducing maternal mortality have been key concerns
of several international summits and conferences,
including the Millennium Summit in 2000.1 One of
the eight Millennium Development Goals (MDGs)
adopted following the Millennium Summit involves
improving maternal health (MDG5). Within the MDG
monitoring framework, the international community
committed itself to reducing the maternal mortality
ratio (MMR), and set a target of a decline of three
quarters between 1990 and 2015. Thus, the MMR
is a key indicator for monitoring progress towards
the achievement of MDG5.
In the Philippines, eleven women die every 24
hours from almost entirely preventable causes
related to pregnancy and childbirth.2 Maternal
mortality ratio (MMR) continues to be staggeringly
high, at 162 maternal deaths for every 100,000
live births3 compared with 110 in Thailand, 62 in
Malaysia, and 14 in Singapore.
Universal access to sexual and reproductive health
education, information, and services improves
health, saves lives and reduces poverty. The slow
decline in MMR in the country may be traced to
inadequate access to integrated reproductive
Expanding choices, uplifting lives through responsive population and human development legislation
I C Y B R I E F
health (RH) services by women, including poor
adolescents and men. Most maternal death and
disability could be averted if:
- all pregnancies were wanted,
- all births were attended by skilled health
professionals and
- all complications were managed in quality
referral facilities offering emergency
obstetric care.4
This policy brief is intended to give guidance to
policy-makers and others engaged in planning and
implementing policies and programs in maternal
health in the Philippines with recommendations
that might be useful in reviewing and assessing
the country’s maternal health care policies and
programs. The analysis is based on a review
of literature, policy documents, tools, and other
relevant materials to bring together up-to-date
evidence from a variety of sources. Moreover,
a focus group discussion was conducted with
selected key informants among officers and
members of the Integrated Midwives Association
of the Philippines (IMAP) who are closely involved
with safe motherhood/maternal health programs
of the country for many years.
2 PLCPD POLICY BRIEF | Philippine Government Policies in Reducing Maternal Mortality

Maternal Health Situation

Results of the 2008 National Demographic and
Health Survey (NDHS) indicate that about 91
percent of Filipino women with at least one live
birth in the 5 years prior to the 2008 NDHS had
received antenatal care from a health professional
compared to 88 percent of the women based on
the 2003 NDHS (Table 1). Among all births in the 5
years preceding the 2008 NDHS, 62 percent were
delivered by a health professional compared to 60
percent reported in the 2003 NDHS.7 While this
represents adequate coverage, there is marked
difference in access across regions and income
groups.

Based on the 2008 NDHS results, the contraceptive

prevalence rate (CPR) of the Philippines is only
50.7 percent (Table 2). This means that only a
little more than half of married Filipino women use
FP methods, whether traditional (16.7 percent) or
modern (34 percent). Only 0.4 percent use “other
traditional method” (natural family planning).

Table 1. Selected maternal care indicators, Philippines: 2003 and 2008 NDHS

Indicators 2003 2008

Percentage of women age 15-49 with one or more live births in the 5 years before the 87.6 91.0
survey who received antenatal care for the youngest child from a health professional
Percentage delivered by a health professional among all births in the 5 years before 59.8 61.8
the survey
Percentage delivered in a health facility among all births in the 5 years before the 37.9 43.8
survey
Sources: 2003 and 2008 National Demographic and Health Surveys

Table 2. Percent distribution of currently married women by contraceptive method used, Philippines: 2003,
2008
Method 2003 2008
Any method 48.9 50.7
Any modern method 33.4 34.0
Any traditional method 15.5 16.7
Not currently using 51.1 49.3
Total 100.0 100.0
Sources: 2003 and 2008 National Demographic and Health Surveys
 PLCPD POLICY BRIEF
This situation leads to more pregnancies and
deliveries among Filipino women. And yet, an
overwhelming majority of Filipinos (92%) believe
that it is important to manage fertility and plan
their family, and most (89 percent) say that the
government should provide budgetary support for
modern artificial methods of FP, including the pill,
intra-uterine devices (IUDs), condoms, ligation,
and vasectomy, based on a 2007 survey on FP
in the Philippines conducted by Pulse Asia.8 In
another survey, the majority (55%) of respondents
said that they are willing to pay for the FP method
of their choice.9
These survey results prove that Filipino women
lack RH care, including information on, and access
to, FP methods of their choice. Births that are too
frequent and spaced too closely take a debilitating
toll on their health, so that many of them die
during pregnancy or at childbirth. Some of them,
despairing over yet another pregnancy, seek an
abortion, from which they also die and along with
them, their unborn child. Based on another study
conducted by the Allan Guttmacher Institute in
2006, of the three million annual pregnancies in
the country, half were unplanned and one-third of
these end in abortions.10
Causes and prevention of maternal deaths
The Philippine government’s MDG progress
report states that 1 in 100 women die as a result
of “maternal causes,” and that maternal deaths
accounted for about 14 percent of all deaths
among women of reproductive age (15–49).11
The underlying causes for the situation are: (1)
inadequate capacity of the health/medical facility
to provide quality emergency obstetric care
(EmOC) services in terms of human resource,
skills, equipment, and medicine; and nonfunctional
referral system for referring high-risk pregnancies.
Lack of awareness on the part of mothers to seek
timely medical care and preference of mothers
to conduct deliveries at their homes are also
contributing factors.
As revealed by the State of Filipino Mothers 2008
report by Save the Children, not only do Filipino
mothers die because of biomedical causes
| Philippine Government Policies in Reducing Maternal Mortality 3
and risk factors, they also lack access to both
lifesaving care and quality maternal/reproductive
health care.12 According to the report, these are
the reasons why Filipino mothers die:
1. limited access to health facilities and
quality maternal care;
2. lack of access to a full-range of reproductive
health care, including family planning
information and services;
3. unplanned pregnancies leading to induced
abortion, and consequently, maternal
deaths;
4. lack of political will to provide maternal
health services;
5. lack of a reproductive health law that
would require appropriate funds to ensure
full access to quality RH information and
services that include maternal health and
family planning.
The dangers of childbearing can be greatly
reduced if a woman is healthy and well-nourished
before becoming pregnant, if she has a health
checkup by a trained health worker during her
pregnancy, and if a skilled birth attendant assists
the birth. The woman should also be checked
during the 12 hours after delivery until six weeks
after giving birth. The government has a particular
responsibility to make prenatal and postnatal
services available, to train health workers to
assists at birth, and to provide special care and
referral services for women who have serious
problems during pregnancy and childbirth.
Unmet need and short birth intervals
Research from developing countries revealed
that unhealthy timing or spacing of pregnancies
is linked to increased risk of multiple adverse
health outcomes.13 14 Following a pregnancy that
occurred quickly after a previous birth, the risk of
a child dying is at least twice as high as that for
longer intervals. A recent study of Filipino women’s
contraceptive needs revealed that one-third of
women at risk did not want to become pregnant
within the next two years, while the remaining two-
thirds did not want any more children.15 Compared
to women who want to end childbearing, women
4 PLCPD POLICY BRIEF | Philippine Government Policies in Reducing Maternal Mortality

Table 3. National Objectives for Health 2005-2010, Philippines

Objectives Indicator Target Baseline Data and

Source
Reduce maternal Maternal mortality ratio per 90 maternal deaths 172 maternal deaths per
mortality 100,000 live births (MDG Target) per 100,000 live births 100,000 live births
(NDHS 1998)
Reduce perinatal Perinatal mortality rate per 18 perinatal deaths 24 perinatal deaths per
mortality 100,000 live births per 1000 live births 1000 live births
(NDHS 2003)
Reduce low birth Percentage of low birth weight 10 percent 12 percent
weight infants infants out of total live births (NDHS 2003)
Reduce risk factors Prevalence rate of iron deficiency 38 percent 43.9 percent
associated with anemia among the pregnant (National Nutrition Survey
maternal morbidity 2003)
and mortality Total contraceptive prevalence rate 80 percent 48.9 percent
(NDHS 2003)
Percentage of deliveries assisted 70 percent 53.9 percent
by skilled birth attendants and in a (NDHS 2003)
health facility (MDG Target)
Percentage of postpartum 80 percent 51 percent
first visit within the first week of (NDHS 2003)
delivery
Source; DOH 2007

who wanted to delay a birth were more likely to be
using no method and therefore to have an unmet
need for contraception.
The Philippines has a contraceptive prevalence
rate (CPR) of over 50 percent, however, available
data and information indicate that the higher risks
of short birth intervals and early pregnancies
still represent a major RH issue. The problem of
short birth intervals is even more pronounced in
younger women, among whom the highest risks
from very short birth intervals are more common.16
To reduce the current number of pregnancies that
occur less than recommended intervals, couples
will need easier access to spacing services that
are responsive to their circumstances.
MDG and ICPD maternal health targets
The Philippines is a signatory to the UN
Millennium Declaration on the global agenda
for development by 2015. Consistent with its
constitutional mandate of making essential
goods, health and other social services available
to all the people at affordable cost, and giving
priority to the needs of the underprivileged,
sick, elderly, disabled, women and children, the
Philippine government has committed to achieve
the Millennium Development Goals (MDGs) by
2015. This commitment includes, among others,
reducing the maternal mortality ratio (MMR)
by 75 percent from 1990 to 2015, along with
increasing access to reproductive health (RH)
by 2015. The health goals and the strategies
to reach these targets are further reiterated in
the Medium Term Philippine Development Plan
2004-2010 and the National Objectives for Health
2005-10 (Table 3).
MDG 5 also highlights the crucial role of midwives
and others with midwifery skills on the path
to improved maternal health by including as
its second indicator the proportion of births
attended by skilled health providers. Although
the percentages are not specified, it is assumed
that the target for 2015, “universal access to a
skilled birth attendant”, translates into between
90 percent and 100 percent coverage.
 PLCPD POLICY BRIEF
Of the eight MDGs, the Philippines is said to be on
schedule except with Goal 5. The rate of decline
in MMR in the Philippines has been quite slow,
declining by only about 22 percent in 13 years
from 209 per 100,000 live births in 1993 to 162
in 200617. Given this trend, there is little likelihood
of the Philippines reaching the 2015 target of 52.
In fact, in its Midterm Progress Report on the
MDGs, the government has already stated that
“goal 5 has been identified as the least likely to
be achieved for the Philippines.”18
As a signatory to the ICPD, the Philippines also
showed marked deficits with respect to meeting
ICPD goals in three specific areas:
- births attended by health professionals;
- contraceptive prevalence rate among
women of reproductive age; and
- maternal mortality.
Health sector reform
The Philippines’ Department of Health (DOH)
initiated the Health Sector Reform Agenda
(HSRA) in 1999. Devolution, following the Local
Government Code of 1991, had fragmented the
health service delivery system as administrative
and financial responsibilities have been shared
since then among central, provincial, and local
authorities, without effective coordination and
cooperation mechanisms in place. As a result,
public health programs suffered most from an
apparent lack of attention. The budget deficit of the
national Government and declining public sector
resources aggravated the situation. HSRA was
introduced to help streamline the health service
delivery system with a comprehensive program
covering five broad areas of reform:19
1. providing fiscal autonomy to hospitals,
2. securing funding for priority public health
programs,
3. promoting the development of local health
systems and ensuring their effective
performance,
4. strengthening capacities of health
regulatory agencies, and
5. expanding coverage of the national health
insurance program.
| Philippine Government Policies in Reducing Maternal Mortality 5
In summary, HSRA was expected to improve the
efficiency of the health service delivery system by
integrating health care promotion and prevention,
improving referral links, reducing the need for
hospitalization, and thereby improving the allocation
and use of resources. Such, however, was not the
case.
The HSRA objective is to shift the burden
of health care costs from household out-of-
pocket expenditures to the public sector and to
PhilHealth. The coverage of the population is to be
expanded, especially to reach the poor (indigents)
and the informal sector by providing packages of
tailor-made benefits. PhilHealth coverage is still
low overall, and very uneven among provinces.
Nationwide, only 20 percent of indigents are
covered. However, counting the enrolled poor is
difficult as poverty data do not exist at municipal
levels, and LGUs cannot appropriately map
where the poor are. In addition, the current
benefits package is limited, and does not provide
preventive health care, or basic curative care
against catastrophic illnesses.20
In 2005, the Department of Health (DOH) also
launched FOURmula ONE (F1) for Health as
the new health sector reform implementation
framework, through which, critical reforms will be
undertaken with “speed, precision, and effective
coordination” and are directed at improving
the efficiency effectiveness and equity of the
Philippine health system. F1 for Health is the
implementation framework for health sector
reforms in the Philippines for the medium term
covering 2005-2010. It is designed to implement
6 PLCPD POLICY BRIEF | Philippine Government Policies in Reducing Maternal Mortality
critical health interventions as a single package,
backed by effective management infrastructure
and financing arrangements.21
Maternal health programs and policies
To concretize its commitment to rapidly reduce
maternal and neonatal mortality, the DOH
issued Administrative Order No. 2008-2009 in
September 2007 to implement a strategy on
integrated maternal and newborn child health
and nutrition (MNCHN). It aims to address service
delivery, regulation, financing, and governance of
the Philippines’ health system.22 The integrated
MNCHN strategy, implemented in all Philippine
provinces and cities, is aimed to meet the
following RH indicators by 2010:
1. increase CPR to 60 percent;
2. increase the proportion of pregnant women
having at least four antenatal care visits to
80 percent;
3. increase skilled birth attendance and
facility-based births to 80 percent; and
4. increase percentage of fully-immunized
children to 95 percent.
Through the MNCHN strategy, the Philippine
government has committed itself to ensure
that:
- every pregnancy is wanted, planned, and
supported;
- every childbirth is facility-based and
managed by skilled birth attendants; and
- mothers and their newborns are provided
with proper post-partum care, as well as
other relevant services included in women’s
health care and the child survival package.
Essential to the MNCHN strategy are facilities
that can provide basic emergency obstetric
and neonatal care (BEmONC). These facilities
should operate on a 24-hour basis, and are
accessible within 30 minutes of travel, equipped
with communication and transportation systems
for referrals. Every BEmONC facility should
have a physician, nurse, and midwife. Also
essential to the MNCHN strategy are the
comprehensive emergency obstetric and neonatal
care (CEmONC) facilities which are accessible
within one hour travel time, operational on a 24-
hour basis, and capable to carry out emergency
responses. A CEmONC facility should be
staffed with at least one obstetrician/surgeon,
pediatrician, anesthesiologist, six nurses, medical
technologist, and six midwives.23
Government health spending
Appropriate investment in health, if used effectively,
improves health standard of the population. In
turn, a healthier population generates incremental
gains in economic growth, which increases
the resources that institutions and households
can use for health. However, those additional
resources need to be distributed and used
equitably to secure higher marginal gains from
the poorer segment of the population.
Based on the 2003 National Health Accounts
(NHA) estimates, national government spending
for health was still predominantly used for the
operation of public hospitals, accounting for about
70 percent. Local government expenditures for
health mainly paid for the operation of general
hospitals (26%) as well as public integrated care
centers, including rural health units (25%), and for
the provision of public health programs (21%).24
Curative care services and medical goods
accounted for 55 and 22 percent, respectively, or a
total of about three quarters, of the national health
expenditures. The remaining health expenditures
went to preventive and public health services (11
%), health administration and insurance including
government regulation (9%), and health-related
services such as research and training (1%).
The top spenders of curative care services were
households (40%), national government (17%),
PhilHealth (15%), and local government units
(10%).25
In 2005, the Philippines’ total health expenditure
went up by 9.4 percent, from P165.3 billion in
2004 to P180.8 billion in 2005. However, the share
of health expenditure to GDP was lower at 3.3
percent in 2005 compared to 3.4 percent in 2004.
It is still below the 5 percent standard set by the
World Health Organization (WHO) for developing
countries. The WHO database showed total per
 PLCPD POLICY BRIEF | Philippine Government Policies in Reducing Maternal Mortality 7

capita expenditure on health in the Philippines Spending for maternal health/FP/RH

was at $177 from 2000–2004. This is relatively
low by comparison to neighboring countries like
Malaysia ($355) and Thailand ($257).26
The government’s target to depend less on out-
of-pocket payments and provide more social
health insurance is still far from being realized
as the share of out-of-pocket payments even
increased to 49 percent while the share of social
insurance payments increased only slightly to
11 percent in 2005. Based on the Health Sector
Reform Agenda (HSRA), the target for out-of-
pocket is 20 percent while the target for social
insurance is 30 percent. Meanwhile, the share
of government on health expenditure declined to
29 percent which is also below the HSRA target
of 40 percent. Filipino household out-of-pocket
expenditures for health were paid for care in
hospitals (23%) and care by ambulatory health
providers (27%), and for drugs purchased from
retail outlets (50%).27
Government commitments to maternal health
can be monitored using financial indicators and
policy approvals. Investment in maternal health
programs can be tracked by measuring inputs
(such as midwifery training), outputs (such as
the number of midwives posted) and processes
(such as the uptake of skilled delivery care).28
These indicators are necessary for planning,
implementing and monitoring initiatives to improve
maternal health.
Based on the 2003 NHA estimates, the Philippine
national government expenditures for preventive
and public health services went to programs for
prevention of communicable diseases (34%)
and non-communicable diseases (23%), and
maternal and child health (9 percent). Similarly,
expenditures of foreign-assisted projects mostly
paid for programs for prevention of communicable
diseases (32%) and non-communicable diseases
(23%), and maternal and child health (22%).29

Box 1. Types of skilled attendants and the mix of skills and abilities34

While it is up to each country to decide on how maternity care should be organized, much depends on the
availability of skilled attendants, the composite set of skills and abilities they possess, and the resources available
to recruit, train and retain these staff. The principal categories of skilled attendants found in many countries
include:

- Midwives (including nurse-midwives): Persons who, having been regularly admitted to an educational
program duly recognized in the country in which it is located, have successfully completed the prescribed course of
studies in midwifery and acquired the requisite qualifications to be registered and/or legally licensed to practice
midwifery.

- Nurses with midwifery skills: Nurses who have acquired midwifery knowledge and skills either as a result
of midwifery being part of their nursing curricula or through special post-basic training in midwifery.

- Doctors with midwifery skills: Medical doctors who have acquired competency in midwifery skills through
specialist education and training, either during their pre-service education or as part of a post-basic program of
studies.

- Obstetricians: Medical doctors who have specialized in the medical management and care of pregnancy
and childbirth and in pregnancy-related complications, but not usually complications of the newly born infant. They
have usually undergone additional education and clinical training to acquire these additional skills and have been
certified or accredited in obstetrics.

Source: Making Pregnancy Safer: the critical role of the skilled attendant. Joint statement by WHO, ICM and FIGO, 2004: 7.
8 PLCPD POLICY BRIEF | Philippine Government Policies in Reducing Maternal Mortality
For the first time, in 2007, the Philippines’ annual
national budget included a specific line item
for FP funding. The General Appropriations Act
(GAA) of 2007 allocated P180 million to the DOH
for operational costs associated with providing
contraceptive services; P30 million for the routine
functions of DOH in support of FP and, through
congressional initiative, another P150 million
to be sub-allocated to LGUs for purchasing RH
commodities and conducting FP seminars.30 As
of the end of 2008, less than one-third of the
budgeted funds had been released to regional
centers for distribution to LGUs.31 Another P1.2
billion was budgeted in 2008, again through
congressional initiative, for the DOH to allocate
to LGUs for procuring RH commodities for free
distribution to the poor. In 2008, the government
national budget allocated P19.8 billion to the
DOH, of which, P386.5 million was allocated to
the Commission on Population (POPCOM).
Skilled Attendance
Skilled care/attendance refers to the care
provided to a woman and her newborn during
pregnancy, childbirth and immediately after birth
by an accredited health care provider who has
at her/his disposal the necessary equipment
and the support of a functioning health system,
including transport and referral facilities for
emergency obstetric care.32 A skilled attendant
Box 2. Models of service delivery for midwifery and
obstetric care
- Model 1: home deliveries by non-professionals
with some training is common in developing
countries, but as untrained birth attendants
cannot manage obstetric complications,
maternal mortality tends to be high
- Model 2: home deliveries by professional
midwives or doctors, with systems available to
refer complicated cases
- Model 3: delivery by professionals in basic
obstetric facilities, with systems to refer
complicated cases
- Model 4: delivery in hospitals, with
comprehensive obstetric care facilities.
Source: Koblinsky, M. A. et al.
is an accredited health professional, such as a
midwife, doctor or nurse, who has 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.33
During pregnancy, skilled attendants monitor the
progress of the pregnancy, detect complications,
provide preventive measures, develop birth and
emergency plans with the woman and her family
and advise women on health, lifestyle and nutrition
in pregnancy.
During childbirth, skilled attendants monitor the
progress of labor, are vigilant for complications
and stay with the women and support them
in many ways. They know how to manage
abnormalities such as breech delivery and, in
a team of various professionals with obstetric,
neonatal and anesthesia skills, they deal
with complications as severe as eclampsia or
obstructed labor.
In the postnatal period, the range of care varies
from helping mothers and babies in breastfeeding
to managing complications such as severe
postpartum bleeding, infection or depression. If
babies have problems, either because of preterm
birth or complications of birth, they receive timely
and appropriate treatment. Skilled attendants also
provide counseling on postnatal contraception to
the mothers.
Preventing the mother-to-child transmission
of HIV is another task of skilled attendants. It
starts in pregnancy with HIV testing, providing
antiretroviral therapy, counseling on infant feeding
and advising on safer sex practices including
the use of condoms and continues in childbirth
by choosing appropriate obstetric practices and
supporting the mother in her choice of feeding the
baby and FP counseling.35
Midwifery in the Philippines
In the Philippine Framework for Maternal Mortality
Reduction,37 health workers are identified as
 PLCPD POLICY BRIEF
playing an integral part in achieving a lower MMR
in the country. However the lack of professional
health practitioners (such as doctors and nurses)
in rural areas in the country is a major concern.
The gap between health need and the available
services is being bridged by the midwives.
Although trained only to provide maternal and
child health care services, midwives are currently
implementing all public health programs.
Midwives constitute a large segment of the
Philippine health personnel sector. In 2005, there
were 16,967 government midwives in the country.
Records show 150,722 registered midwives as
of June 2007, of which, 3,498 were registered
in 2007. Midwives work in the private or public
sector, in hospitals, birthing clinics, barangay
health stations, or rural health units, or they work
abroad. They comprise 65 percent of the public
health workforce. In the rural areas, they are the
first point of contact for patients coming into the
health system.38
Midwives, as the public health workers at primary
health care facilities, are the main implementers of
the county’s health programs. Its original focus of
providing maternal and child health care has become
only one of the many responsibilities they have to
handle. More than 40 programs of the DOH rest
on the midwives’ shoulders, including immunizing
mothers and their children. In the rural areas,
midwives are on-call 24 hours a day, seven days a
week. This working arrangement has not changed
for decades and is expected to continue in the future.
Midwives and community health workers often have
no equipment at all, no transport except their feet,
and they work under the most difficult of conditions.
Although the recommended ratio was one midwife
for every 3,000 individuals, many midwives have
10,000-30,000 individuals in their catchment area.
Traditional birth attendants
Community midwives are officially labeled ‘traditional
birth attendants’ (TBAs) by World Health Organization
(WHO) and United Nations Children’s Fund
(UNICEF) because they do not meet the international
definition of a midwife and are not considered skilled
attendants. Since 1990, international agencies
| Philippine Government Policies in Reducing Maternal Mortality 9
and academics, without robust evidence, have
persuaded governments to stop training TBAs.
Furthermore, TBAs, regardless whether or not they
have received training, are being excluded from
having a role in maternity care programs.
When the professional midwives make a sincere
effort to learn about and honor local customs and
traditions, when they approach local people with
an attitude of respect and demonstrate willingness
to work with TBAs, honoring them as colleagues,
this hierarchical system can function effectively.39
In such cases, TBAs are generally very willing to
advise women to go to the clinic or hospital. But
when doctors and professional midwives approach
the community with an attitude of arrogance, treat
the TBA with disdain and punish women who attempt
homebirth by treating them badly, mothers and their
at-home attendants avoid the clinic or hospital at all
costs. Such a situation leaves the TBA to cope with
emergencies as best as she can; often until too late
to seek help.40
A study in 2006 proved that facility-based births with
skilled midwives and assistants working under TBA
supervision effectively increased the number and
proportion of women with professionally assisted
births.41 These findings support the idea of a health
care model, where trained TBAs work under close
supervision of authorized midwives. Countries such
as Malaysia that have successfully moved from
the use of TBAs to skilled birth attendants even
sought to include TBAs as partners and allies in the
process, and constructively used their social status
and relationships in the community to promote the
use of skilled birth attendants.
10 PLCPD POLICY BRIEF | Philippine Government Policies in Reducing Maternal Mortality

Table 4. Evidence-based package of care required to reduce maternal mortality­42

Evidence based package of care Details

Sexual and reproductive - Providing the ability to space births and also to help
health services including prevent sexually transmitted diseases such as HIV. Up to
family planning 35% of maternal deaths could be averted through better
access to family planning.43 44
- Providing adolescents with information and education
about sexuality and reproduction has been shown to
increase the age of sexual debut and delay the age of the
1st pregnancy.45
Care for adolescent girls46 Nutritional education and iron-folate supplements to girls aged
10-18 years in countries with
high prevalence of anaemia ensures that women enter their
reproductive years in good health
and are likely to protect them against maternal mortality and
low birth weight babies.47
Antenatal care - At least 4 visits during the pregnancy.
- Iron supplements – can prevent up to 23% of maternal
deaths if malaria also prevented48
- Vitamin A supplements – critical to handling infection.49
- Folate supplements.50
- Other nutrition support including the fortification of staples
- at least 20% of maternal deaths are linked to poor
nutrition.51
- Breastfeeding and family planning counseling.
- Maternal tetanus immunization.
- Preventative malaria treatment and bed nets.
- Birth planning and preparation.
- Antiretroviral drugs to prevent HIV transmission from
mother to child (PMTCT).
Skilled birth attendants - Early identification of complications.
(doctors, midwives and - Clean and safe delivery practices.
nurses) - Birth in facility.
- Field responses to infections and bleeding-infection may
be involved in up to 75% of maternal deaths.52
Timely access to emergency Manage complications during labour, birth & after birth using
obstetrics services emergency obstetric care (EMOC)
principles:
- timely transport from home to facility and from facility to
higher level care.
Postnatal and newborn care At least two postnatal visits by health staff:
- 1st home visit within 3 days of home birth
- 2nd within 6 weeks at the clinic.
Main threats: bleeding, sepsis, and anaemia.
Source: World Vision and The Nossal Institute for Global Health, 2008
 PLCPD POLICY BRIEF
In the Philippines, TBAs are found in almost every
barangay and in many urban neighborhoods. In
these areas, they deliver the majority of births.
Therefore, the potential of TBAs as FP change
agents cannot be ignored. The TBA has a potential
role to play in modern maternity care programs
in the country. However, eliminating traditional
health practices and beliefs that work against the
common good should be one of the main areas
to be addressed in mobilizing TBAs for them to
participate effectively in maternal care programs.
Instead of excluding TBAs from providing maternity
care, they may be considered as resource
persons, who could be involved in maternity care
programs, provided they are working under close
supervision from trained nurses/midwives. Hence,
alternative strategies where TBAs knowledge and
skills are acknowledged and incorporated within
the existing health system may prove beneficial.
Policy Options and Recommendations
Some of the policy options that the Philippine
Legislators’ Committee on Population and
Development (PLCPD) Foundation recommends
to reduce maternal mortality in the country are as
follows:
Promote the rights perspective to health care
A rights perspective helps legitimize prioritizing
women’s health. Strong political support and
national ownership are essential to create
enabling health policies, to attract resources for
safe motherhood, and to ensure those resources
reach groups with the highest maternal mortality.
The right to health includes entitlements to a range
of health interventions which have an important
role to play in reducing maternal mortality. The
government has an obligation to provide goods
and services in order to prevent maternal mortality.
These include:
- Emergency obstetric care (EmOC);
- A skilled birth attendant;
- Education and information on sexual and
reproductive health;
- Other sexual and reproductive health care
services, such as family planning services;
| Philippine Government Policies in Reducing Maternal Mortality 11
- Primary health care services.
Provide clear policy framework
A comprehensive approach to accelerating
progress in maternal health begins with a clear
national policy framework that encompasses
multiple levels, from presidential decrees and
statutory laws to health systems’ policies,
standards, and protocols. Many laws and
policies that fall completely outside the health
sector also have a bearing on maternal health.
These include laws and regulations relating
to education, social welfare, transport, justice,
finance, employment, etc. Government has the
responsibility to ensure that the laws, regulations,
and policies that affect particular aspects of
maternal health are harmonized and are in line with
human rights enshrined in national constitutions,
regional and international human rights treaties,
and international consensus documents. The
Philippine Congress should enact the proposed
Reproductive Health and Population Development
Act of 2008 which aims to promote information
and access to natural and modern FP; breast
feeding, prevention of abortion and management
of post-abortion complications; adolescent and
youth health; prevention and management of
reproductive tract infections, HIV/AIDS and
STDs; elimination of violence against women;
counseling; treatment of breast and reproductive
tract cancers; male involvement and participation
in RH; and RH education for the youth.
Integrate family planning in safe motherhood
program
Family planning can prevent many maternal
deaths by helping women prevent unintended
pregnancies and by reducing their exposure to
the risks involved in pregnancy and childbirth. FP
allows women to delay motherhood, space births,
prevent unsafe abortions, protect themselves from
sexually transmitted infections (STIs), including
HIV/AIDS, and stop childbearing when they have
reached the desired family size.
More lives would certainly be saved if all women
had access to good prenatal, delivery, and
12 PLCPD POLICY BRIEF | Philippine Government Policies in Reducing Maternal Mortality
Box 3. WHO recommendations for birth spacing
Birth spacing after a live birth: After a live birth,
the recommended interval before attempting the
next pregnancy is at least 24 months in order to
reduce the risk of adverse maternal, perinatal
and infant outcomes.
Birth spacing after an abortion: After
a miscarriage or induced abortion, the
recommended minimum interval to next
pregnancy is at least six months in order to
reduce risks of adverse maternal and perinatal
outcomes.
Source: World Health Organization, 2006 Report of a WHO Tech-
nical Consultation on Birth Spacing.
postpartum care. It must also be acknowledged
that the interventions to reduce maternal death
also significantly contribute to reducing newborn
mortality.
Make emergency obstetric care available to all
women
In addition to facility based skilled attendance,
a well functioning health system with provision
of equipment, drugs and other supplies is
needed for the effective and timely management
of delivery complications, which may lead to
maternal deaths. Recently, much emphasis
has been on making emergency obstetric care
(EmOC) available to all women, who need it. It
does not imply that all births should take place
in well-equipped health facilities, but only that
if a pregnant woman develops complications,
she should be able to access essential obstetric
care. To ensure improved access to EmOC, a
well functioning referral system is mandatory.
This means overcoming delays in recognition
of complications and in gaining timely access
to appropriate EmOC facilities.53 Additionally,
for those women who develop obstetric
complications, a health worker (or team of
health workers) who is trained, authorized, and
supported to deliver the emergency care required
has to be present.
Promote healthy timing and spacing of pregnancy
Communication, counseling and services for
adolescents should focus on the health risks
associated with the timing of a first pregnancy and
birth. Healthy timing and spacing of pregnancy
(HTSP) is an intervention to help women and
families delay or space their pregnancies to
achieve the healthiest outcomes for women,
newborns, infants, and children, within the context
of free and informed choice.
Specific recommendations for HTSP:54
- Implement HTSP behavior change
communication and counseling
interventions as an integral risk prevention
strategy in all FP, child and maternal health
communications and client counseling
protocols.
- Ensure that the two 2006 WHO pregnancy
spacing recommendations, as well as
information on the specific health benefits
associated with the healthy timing and
spacing of pregnancy are included in all
communications and protocols.
- Develop or strengthen pregnancy delay
or spacing services and communication
activities for young (15-29 years) clients.
- To achieve a more balanced method
mix, help families understand that long-
acting and intermediate methods (IUDs
and injectables) are safe, and can
effectively help them achieve their spacing
preferences.
Reduce impact of unsafe abortion
The ICPD commitment to address the problem
of unsafe abortion is reflected in Paragraph
8.25 in the ICPD PoA, which acknowledges that
improving abortion-related care is an essential
strategy for improving women’s health. On this
background and based on years of advocacy
by NGOs on the need to integrate sexual
and reproductive health objectives into the
MDGs, 55 it was in 2005 suggested that the
risks women face from unplanned births and
unsafe abortion should be incorporated into the
monitoring of the MDG framework.56 In October
 PLCPD POLICY BRIEF
2006, the United Nations’ General Assembly
gave its endorsement to include universal
access to reproductive health by 2015 as one
of the international community’s Millennium
Development targets.57
Revise midwifery law
Proposed amendments to the midwifery legislation
in the country aim to enhance the standards of the
profession by raising the passing rate in licensure
examinations and expanding the responsibilities
of midwives to perform their functions.
Promote entrepreneurship among midwives
Midwives in the Philippines can be trained to open
and manage midwife clinics to provide affordable,
quality, convenient health care to clients in the
lower- and middle-income markets.
Promote partnership with traditional birth attendants
In spite of strong advocacy for facility based
deliveries, some Filipino women will choose to
deliver at home either with a skilled attendant,
a community health worker (CHW) or a TBA.
For mothers who deliver at home, facility based
obstetric care alone is not likely to be a credible
strategy for reducing maternal death. Therefore,
along with the strategy of aiming at increasing
the number of health facility based deliveries,
some preventive functions of basic care targeting
women who prefer to deliver outside the health
facilities should be developed. Such strategies
have been evaluated and found to be associated
with low maternal mortality ratio in the Netherlands
and Malaysia.58
In practical terms TBAs can help in the provision
of skilled care to women and newborns by:
- serving as advocates for skilled attendants
and maternal and newborn health needs;
- encouraging women to enroll for essential
pre- and postnatal care and to obtain care
from a skilled attendant during childbirth
- helping women and families to follow
up on self-care advice and other
| Philippine Government Policies in Reducing Maternal Mortality 13
recommendations (nutrition, treatment,
dietary supplementation, immunization,
scheduled appointments, plan for births
and emergencies, etc.);
- encouraging the involvement of the male
partner in the care of the woman and their
newborn;
- disseminating health information through
the community and families (danger signs,
where and how to seek care, healthy
life styles, where to seek assistance for
other RH needs such as FP, neonatal
immunization, etc.) where this role is not
the mandate of the skilled attendant;
- giving social support during and after
delivery, either as a birth companion or by
supporting the household while the woman
is away for childbirth;
- informing the skilled attendant about
women who have become pregnant
in the community so that the skilled
attendant can make direct contact with
them;
- serving as a link between families,
communities and local authorities and the
RH services; and
- encouraging community involvement
in the development/maintenance of the
continuum of care.
Strengthen the health system
Key elements of the Philippine health system
that must be strengthened include sufficient
numbers of health providers with midwifery
skills, and immediate access to emergency
obstetric care for all women who experience a
complication in pregnancy or childbirth. Maternal
mortality reduction is, in the first place, a matter
of strengthening health systems, including human
resources. It is access that counts: to skilled
attendance, to emergency obstetric care, to
family planning and to safe abortion. In addition,
innovative community approaches are important to
enhance local ownership, develop local solutions
and bridge the gap between communities and
services. Health systems research, finally, is
needed to generate new evidence and keep fine-
tuning national policies to realities.
14 PLCPD POLICY BRIEF | Philippine Government Policies in Reducing Maternal Mortality

Conclusion The Philippine government should also start

Increasing access to skilled and timely care is
a key to reducing the toll of maternal deaths.
Failures occur at household and community
level, through poverty, gender bias, and lack of
awareness on the needs of pregnant women. They
occur at: (1) service delivery level through lack
of accessible, well functioning, and staffed and
resourced facilities; and at (2) policy and systems
level through poor planning, management and
supervision, and lack of political commitment.
Attention also needs to be given to cost effective
ways of measuring and monitoring maternal
mortality and morbidity.
Almost all maternal deaths could be prevented if
skilled midwifery care was available to mothers
during pregnancy and childbirth, with effective
referral systems in place for emergencies.
However, in many places in the Philippines,
the services of skilled birth attendants are not
available and TBAs are women’s only source
of care. TBAs can provide culturally appropriate
nurturing in the community setting, offer a first-line
link with the formal healthcare system, and provide
some simple services such as the distribution of
nutrition supplements. A useful strategy in a range
of settings has been to train TBAs to recognize
problems during delivery and, when necessary, to
guide women to and through the formal healthcare
system. Where TBA training is undertaken, it
should be part of a broader strategy that includes
a built-in mechanism for referral, supervision, and
evaluation59.
considering other options in addressing the
issue on population growth, such as the pending
bills on RH in Congress. One of those is the
proposed Reproductive Health and Population
Development Act of 2008. Essentially, a good
and progressive policy should be able to
empower the poor by affording them access to
pertinent information on RH as well as important
services, particularly on maternal health.
This should coincide not only with the goal of
sustainable human development but poverty
reduction as well, considering that higher fertility
occurs more often in lower-income groups60.
Finally, the maternal health (Goals of the the
MDGs)will not be met without rapid action to:
- increase awareness of the nature and
scale of the problem, making it visible to
politicians, professionals, and the public
thereby creating a powerful catalyst for
change;
- increase investment in strengthening
health systems and in improving access
to RH services generally and to maternal
health services specifically; and
- address the wider social, cultural, and
economic barriers to better maternal
health, including the unequal status and
rights of women.

Underlying high levels of maternal death and

disability is the failure to assure women’s rights
and gender equality. Women’s low status and
lack of power, poor access to information and
care, restricted mobility, early age of marriage,
and the low political priority and resources
given to their health all contribute to high
maternal mortality ratios. In the Philippines,
overcoming this means challenging the cultural
and political norms and legal frameworks
that limit women’s ability to make informed
choices about, and take appropriate actions to
ensure, healthy sexual and reproductive lives.
 PLCPD POLICY BRIEF
Endnotes
1
United Nations Millennium Declaration. Fifty-fifth
Session of the United Nations General Assembly. New
York: United Nations; 18 September 2000. (General
Assembly document, No. A/RES/55/2).
2
Commission on Population (POPCOM). State of
the Philippine Population Report: Time to Act: Needs,
Options, Decisions, State of Philippine Population Report
2000, Mandaluyong City: POPCOM, 2001.
3
National Statistics Office (NSO), 2006 Family
Planning Survey.
4
WHO. op cit.
5
Ibid.
6
NSO, 2006 Family Planning Survey, Manila: NSO,
2006.
7
NSO, 2008 National Demographic and Health Survey,
Preliminary Report.
8
Pulse Asia, Ulat ng Bayan survey media release on
family planning, March 2007. Available at
9
http://pulseasia.com.ph/pulseasia/story.asp?id=545.
Social Weather Stations, SWS 4th Quarter 2004 survey
report on family planning for the Department of
Health (DOH), 24 Feb. 2005.
Available at http://www.sws.or.ph.
10
Singh S et al., Adding It Up: The Benefits of Investing
in Sexual and Reproductive Health Care. New York:
The Alan Guttmacher Institute and United Nations
Population Fund, 2003.
11
Government of the Philippines. Philippines Progress
Report on the Millennium Development Goals. Manila:
Government of the Philippines and United Nations,
2003.
12
Save the Children, State of Filipino Mothers 2008:
Saving Mothers’ Lives, Ensuring Children’s Survival,
March 2009.
13
Conde-Agudelo A, Rosas-Bermúdez A, and Kafury-
Goeta AC, “Birth Spacing and Risk of Adverse
Perinatal Outcomes: A Meta-analysis,” Journal of the
American Medical Association 2006;295:1809-1823.
14
Da Vanzo, J., Razzaque A, Rahman M, Hale L, Ahmed
K, Khan MA, Mustafa G and Gauzia K, “The Effects
of Birth Spacing on Infant and Child Mortality,
Pregnancy Outcomes, and Maternal Morbidity and
Mortality in Matlab, Bangladesh,” Rand Corporation:
Rand Labor and Population Working Paper Series, WR-
198, October 2004.
15
Darroch JE, Singh S, Bal H, Cabigon JV, “Meeting
women’s contraceptive needs in the Philippines,” Issues
in Brief, Alan Guttmacher Institute 2009;1:1-8.
| Philippine Government Policies in Reducing Maternal Mortality 15
16
Jansen WH, “Extending Service Delivery (ESD)
Project: Country profile: Philippines,” Washington
DC: U.S. Agency for International Development
(USAID) Bureau for Global Health, (n.d),
17
National Statistics Office, op cit.
18
Philippines midterm Progress Report on the
Millennium Development Goals, page 34.
19
The Health Sector Reform Agenda (HSRA) does not
include two priority areas of human resource development,
or improving the health information systems. HSRA-plus
will include these two cross-cutting areas.
20
Asian Development Bank, Technical Assistance to the
Republic of Philippines for the Support for Health
Sector Reform (TAR: PHI 39066), Sept 2005
21
Department of Health, Philippines website, < http://
www.doh.gov.ph/fourmulaone>.
22
Save the Children, op cit.
23
Ibid.
24
National Statistical Coordination Board (NSCB), 2003
Philippine National Health Accounts, NSCB, 2004,
in Racelis, Rachel H “The National Health Accounts
of the Philippines: Continuing Development and
New Findings, “Philippine Journal of Development,
FindArticles.com, <http://findarticles.com/p/articles/
mi_qa5519/is_200601/ai_n21407228/>.
25
Ibid.
26
World Health Organization (WHO), National Health
Accounts, World Health Statistics, 2006.
27
NSCB, 2004, op cit.
28
Wardlaw T and Maine D, “Process indicators for
maternal mortality programmes,” in Reproductive
Health Matters. Safe Motherhood Initiatives: Critical
Issues, Oxford: Blackwell, 1999:24-30.
29
Ibid.
30
Darroch JE et al, op cit.
31
Office of the Secretary, Department of Health
(Philippines), Department memorandum 2008-0272,
Dec. 16, 2008. Available at <http://home.doh.gov.ph/
dm/dm2008-0272.pdf>.
32
World Health Organization (WHO), “Making
pregnancy safer: the critical role of the skilled
attendant,” Joint statement by WHO, ICM and
FIGO, 2004:1. (This revised definition has been
endorsed by the United Nations Population Fund and
the World Bank.)
33
Ibid.
34
WHO, 2004, op cit.
35
WHO. 2005, op cit.
16 PLCPD POLICY BRIEF | Philippine Government Policies in Reducing Maternal Mortality
36
Koblinsky, M. A., C. Conroy, N. Kureshy, M. E.
Stanton, and S.Jessop, Issue in Programming for Safe
Motherhood, Washington, D.C.: MotherCare/JSI, 2000.
37
Department of Health, Philippine Framework for
Maternal Mortality Reduction. Available at http://doh.
gov.ph/mmr/mmr_framework.htm
38
International Confederation of Midwives , “Midwifery
in the Philippines,” 2008.
39
Davis F, “Some perspectives on global issues in
midwifery,” Midwifery Today, in Women’s International
Network News, Summer 2000;26.3:22-23
40
Ibid.
41
Koblinsky M, Matthews Z, Hussein J, Mavalankar D.,
Mridha M.K., Anwar I., et al, “Going to scale with
professional skilled care,” Lancet 2006;368:1377-86.
42
World Vision and The Nossal Institute for Global
Health, University of Melbourne, “Reducing maternal,
newborn and child deaths in the Asia Pacifc: Strategies
that work.” Melbourne: World Vision and The Nossal
Institute for Global Health, University of Melbourne,
2008:4.
43
Department for International Development (DFID),
“DFID 2004 Maternal health strategy: Reducing
maternal deaths: evidence and action,” London: DFID,
2007:9.
44
Bernstein S. et al, “Sexual and reproductive health:
completing the continuum,” Lancet 2008;372:1225-6.
45
Bearinger L. et al, “Global perspectives on the sexual and
reproductive health of adolescents: patterns, prevention,
and potential,” Lancet 2007; 369:1220-1231.
46
A more extensive care continuum advocated by some
authors includes adolescent health support. For
example see Kerber K et al, “Continuum of care for
maternal, newborn, and child health: from slogan to
service delivery” Lancet 2007;370:1358-69.
47
World Health Organization, Regional Office for
South-East Asia (WHO-SEARO), Adolescent Nutrition:
A Review of the Situation in Selected South-East Asian
Countries, New Delhi: WHO-SEARO, 2006:47-50.
PEOPLE COUNT
PLCPD POLICY BRIEF 2009
A publication developed by the Philippine Legislators’ Committee on Population and Development Foundation, Inc. (PLCPD)
with support from United Nations Population Fund.
2/F AVECSS Building, #90 Kamias Road. cor. K-J Street, East Kamias, Quezon City 1102, Philippines
Tel. nos.: (+632)925-1800 • (+632)436-2373
E-mail: plcpdfound@plcpd.org.ph
Website: http://www.plcpd.org.ph
Executive Director: Ramon San Pascual, MPH
Editors: Floreen M. Simon, Ernesto Almocera, Jr. and Romeo C. Dongeto
Layout: Dodie Lucas
48
Black R et al, “Maternal and child undernutrition:
global and regional exposures and health
consequences,” Lancet 2008;371:243-260.
49
West K et al, “Double blind, cluster randomised trial
of low dose supplementation with vitamin A or beta
carotene on mortality related to pregnancy in Nepal,”
BMJ 1999;318:570-75.
50
Evidence is building to suggest that child and maternal
mortality can be further reduced by additional
micronutrient supplementation beyond iron, folate and
Vitamin A e.g. see Shankar A et al, “Effect of maternal
multiple micronutrient supplementation on fetal loss
and infant death in Indonesia: a double-blind cluster-
randomised trial” Lancet 2008;371:215-27.
51
Black R et al , op cit.
52
Costello A et al, “An alternative strategy to reduce
maternal mortality” Lancet 2006;368:1477-9.
53
Thaddeus S and Maine D., “Too far to walk: maternal
mortality in context,” Soc Sci Med 1994;38:1091-110.
54
Jansen, op cit.
55
Rasch, V, Maternal death and the Millenium
Development Goals,” Dan Med Bull 2007;54:167-9.
56
Technical consultation on reproductive health
indicators, summary report 2006, Geneva: World
Health Organization, 2006.
57
Family Care International, <http://www.familycareintl.
org/en/issues/24>, 2007.
58
Koblinsky M, Campbell O, Heichelheim J.,
“Organizing delivery care: what works for safe
motherhood?” Bull World Health Organ 1999;399-406.
59
Reduction of maternal mortality. A joint WHO/
UNFPA/UNICEF/World Bank statement, Geneva:
WHO, 1999.
60
Garcia P and MJ Vital, “Living on the edge,”
BusinessWorld, 24 July 2009. Available at http://www.
bworldonline.com/BW072409/content.php?id=059.
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