Policy Brief No. 1 2010
The issue on hand
In its 2009 State of the World’s Children report, the United Nations Children’s Fund (UNICEF) had the following statistics for the Philippines: 70 percent of pregnant women had at least four antenatal check-ups, 60 percent had skilled attendants at birth, and 38 percent had institutional deliveries. While the country registered higher in terms of antenatal care than the regional figure of 66 percent for East Asia and the Pacific, the Philippines’ achievements with regard to having skilled birth attendance and facility-based deliveries are trailing below the regional averages of 87 and 73 percent, respectively. Skilled birth attendance (SBA) is helpful in reducing the risk of postpartum hemorrhage, a leading cause of maternal deaths. SBA is defined as deliveries conducted with the presence of a doctor, nurse, or midwife. The presence of skilled birth attendants (SBAs) during delivery is important as they are able to recognize complications that will require referral for more specialized emergency care. According to UNICEF, around 15 percent of births are likely to need emergency obstetric care, requiring birthing facilities that should have sufficient medicines, supplies, equipment, and trained personnel.
What do the evidence show?
A study on local services delivery by the UNICEF and the Philippine Institute
Hilots getting on board facility-based deliveries Skilled birth attendance (SBA) is helpful in reducing the risk of postpartum hemorrhage, a leading cause of maternal deaths. The presence of skilled birth attendants (SBAs) during delivery is important as they are able to recognize complications that will require referral for more specialized emergency care. for Development Studies (PIDS) reveals that a key challenge for SBA delivery is to reach patients residing in far-flung areas. Hard-to-reach barangays, usually in mountainous areas, have poor accessibility due to lack of good roads. Normally, these areas have no barangay health stations (BHS) nor permanent midwives assigned. While health personnel are supposed to visit these areas on a regular basis, there are times when it becomes difficult to do so because of the presence of insurgents. It is not surprising therefore for the local residents, especially the women, to enlist the services of traditional health attendants who usually live in the area such as hilots or traditional birth attendants (TBAs) for certain health concerns, in particular, birth deliveries.
Table 1. Average child birth expenditure by service provider (in PHP)
By Birth Attendant: Doctor Nurse Midwife Hilot
Agusan del Sur Obs* Mean 24 11 25 60
10,251.04 6,909.09 1,218.00 947.50
Dumaguete Obs* Mean 71 10 4 10
6,079.51 4,166.00 3,175.00 755.00
Source: UNICEF-PIDS Local Services Delivery, Household Survey, Health Module * Number of observations
Cost is another major hindering factor for SBA deliveries. In Agusan del Sur, for instance, a large percentage of women delivered with the aid of hilots who charge less than PHP1,000 as compared with the PHP10,251 charged by doctors and PHP6,900 by nurses (Table 1). And while the variance in the prices charged by midwives (at PHP1,218) and hilots is relatively slight, focus group discussion (FGD) respondents said that they prefer hilots because they are more approachable. Midwives are usually present only during deliveries while hilots stay for a longer period to feed the mothers, sometimes even to wash their clothes. Pregnant women also feel embarrassed to seek the assistance of SBAs because they feel that they have to show adequate supplies during deliveries such as clean towels, linens, baby clothes, disposable diapers, and “presentable” kettles for sterilization. Recognizing these challenges, the Department of Health (DOH) began to train hilots as early as 1974. In 1994, a Department order was issued “allowing trained hilots to attend normal home deliveries especially in areas where services of the registered midwife or licensed trained health personnel are not
The Filipino child
available at all times.”1 Despite these efforts, however, the National Demographic and Health Survey (NDHS) notes that the quality of care that hilots deliver is questionable, especially as seen vis-avis the care given by other SBAs (Table 2). Pregnant women whose prenatal attendants are hilots normally receive inadequate prenatal care which might prevent the early detection of possible complications. In fact, the DOH’s latest manual of operations for the rapid reduction in maternal and neonatal mortality admits that “training of TBAs [or hilots] has had little impact on maternal mortality” and “the best intrapartum-care strategy is likely to be one in which women routinely choose to deliver in a health center, with midwives as the main providers, but with other attendants working with them in a team” (DOH 2009). Indeed, in some local government units (LGUs) where this strategy of institutional deliveries with SBAs present is followed, there has been a marked decrease in maternal mortality. For instance, in the province of Biliran, when it has not yet passed an ordinance prohibiting hilots from attending births, ten pregnant women died every year. When said ordinance was passed and implemented,2 the number of pregnancyrelated deaths went down. The same case happened in the city of Tayabas where maternal mortality decreased to zero in 2007 when it did not allow hilots to attend to births and when it set up birthing clinics in every barangay. When the mayor once again allowed hilots to attend to births, maternal mortality went up to three in 2008.3
Policy Brief No. 1
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Table 2. Prevalence of prenatal care according to quality and type of prenatal attendant Prenatal Attendant
Poor 2003 2008 p value
Fair 2003 2008 p value
Good 2003 2008 p value
Doctors Nurse/Midwife Hilot
8.5 21.1 88.5
40.1 55.2 9.2
51.7 23.7 3.6
2.7 13.2 93.0
0.00 0.00 0.02
24.2 47.2 2.8
0.00 0.00 0.00
73.2 39.7 4.2
0.00 0.00 0.98
Note: If p value is less than .05, there is a significant difference between 2003 and 2008 estimates. Source: Lavado, Lagrada, Ulep, and Tan (2010). Prevalence and correlates of good quality prenatal care in the Philippines.
the presence of SBAs are being promoted. Moreover, the continued patronage by some pregnant women of the hilots’ services for reasons cited earlier plus the strong lobbying done by hilots against such ordinances calls for a strategy that would reconcile said pregnant women’s perceptions about hilots and the principles outlined in the current MNCHN policy. In this regard, it will be useful for the DOH to issue an AO that would explicitly state a new role—and what it will be—for hilots in the Department’s present MNCHN strategy. To ensure that hilots will not feel sidestepped in the new strategy pursued by the DOH, there should be proper incentives to persuade them to refer their clients to medical personnel. A current strategy espoused by the Women’s Health and Safe Motherhood Project (WHSMP) calls for the inclusion of hilots in the Women’s Health Team (WHT). Through the Facility-based Childbirth Performance-based Grant, WHTs are given a PHP1,000 incentive for every pregnant woman they refer to a BEmONC or CEmONC facility for childbirth services. Since this amount is bigger than what is being charged by
hilots in assisting deliveries, this may be enough incentive for them to refer their clients to facilities. The province of Biliran has implemented this strategy by incorporating hilots in the rural health unit as part of the WHT. The hilots get 30 percent of the PHP1,000 that the pregnant mother pays the hospital or birthing center. Hopefully, similar arrangements can also be made for other provinces that are not yet part of the WHSMP project, where a possible source of funds is reimbursements from PhilHealth. And hopefully, this may lead to better maternal and child care services in the whole country. ____________ Department Circular No. 69-A s 1994, dated April 22, 1994. 2 “Traditional hilot gives way to birthing clinics in Biliran” by Ashzel Hachero, Malaya, March 23, 2009. http://www.malaya.com.ph/mar23/ news4.htm. 3 “Does shifting to facility-based delivery improve MCH services: the case of barangay health stations as birthing homes in Tayabas, Quezon” by Dr. Nelson I. Palayan, Dr. Leizel P. Lagrada, and Dr. Rouselle F. Lavado, presented during the 9th National Forum on Health Research for Action, June 2009. 4 AO 2008-0029. “Implementing Health Reforms for Rapid Reduction of Maternal and Neonatal Mortality.” 1
What can be done?
While the DOH’s manual of operations was straightforward on the role of hilots, the Administrative Order4 (AO) issued by the Department was not that explicit on its policy on hilots. This poses a problem at the LGU level because medical officers have no clear policy to hold on to, which makes it difficult for them to convince LGU officials to pass an ordinance supporting Maternal, Neonatal, and Child Health and Nutrition (MNCHN) policies where institutional child deliveries and
Philippine Institute for Development Studies NEDA sa Makati Building 106 Amorsolo Street, Legaspi Village 1229 Makati City Tel. Nos.: (63-2) 8942584/8935705 Fax Nos.: (63-2) 8939589/8942584 Email: publications@pids.gov.ph Website: http://www.pids.gov.ph
The Filipino Child Policy Brief is culled from studies under the joint UNICEF-PIDS project titled “Global study on child poverty and disparities: Philippines.” It highlights specific issues on child poverty in the Philippines and draws out their implications for policy. The author is Rouselle F. Lavado, Senior Research Fellow at the Institute. The views expressed are those of the author and do not necessarily reflect those of UNICEF policy or programmes and PIDS.