BRINGING MOTHER- AND BABY-FRIENDLY
BIRTH CENTERS TO THE PHILIPPINES

 

Vicki Penwell

 

SYNOPSIS

I studied the first 7,565 women were admitted for labor and delivery in two charity birth centers that I established in the Philippines through Mercy In Action, the faith-based, non profit organization our family founded (see www.mercyinaction.org). The births in this study occurred between February 8, 1996 (the day the first woman delivered in our newly established birth center) and December 31, 2003 (when we ended the study to begin compiling data for my Master's thesis). All the women who were admitted for delivery are included in this reporting. (Women risked out prior to labor are not included in this study.) Midwives conducted all of the deliveries. These were Certified Professional Midwives (CPMs)*¹ or Licensed Midwives (LMs)*² from the USA and the Philippines.  In the vast majority of cases, student midwives under direct supervision helped "catch" the babies as they were born, and assisted in all aspects of maternity and newborn care. All students represented in this study were enrolled Mercy In Action's program for midwifery and primary health care training, and dual-enrolled as candidates for an accredited Associate of Science in Midwifery degree from the National College of Midwifery (see www.midwiferycollege.org and chapter 10, this volume). The birthing women were at higher than average risk of a poor pregnancy outcome because of demographic factors: most were poor, often malnourished and living in crowded urban slum conditions. 92% of the women and 34% of their spouses were unemployed, and the average income was the equivalent of less than US $2 per day.  Only a little over half were married.

In spite of the poverty, 95% of these women had spontaneous vaginal births; 83% had blood loss less than 500 ml, with only 2% having blood loss greater than 1000 cc. 85% of the babies required no resuscitation effort; 67% of the labors were without fetal distress or meconium staining; and 90% of the babies were of normal birth weight. Transfers to a hospital after admission to the birth center occurred 7% of the time, with 3% of transports during first stage and 0.5% during second stage. Less than half of these transports resulted in caesarean section births. One and one-half percent of total deliveries transported during the postpartum period, and 2% were referrals for the baby to be seen by a doctor. Neonatal mortality was 4.1/1000, four times lower than the neonatal mortality rate of 18/1000 for the Philippines as a whole. Maternal mortality was 53/100,000 births, compared with 200/100,000 births for the Philippines, also 4 times lower than the nation as a whole, and when adjusted for causes of death that were not directly related to the pregnancy or birth, that figure was halved, to 26/100,000 births (Penwell 2005).

When I conducted the research for my Master's thesis for the National College of Midwifery, my friend and mentor Elizabeth Gilmore suggested I write my null hypothesis stating that I expected our outcomes for these 7,565 births to be worse than the national average for the Philippines. My hypothesis read as follows:

The null hypothesis is that all these women would have worse outcomes than a similar group of women, for the following reasons based on usual assumptions:  because all deliveries were conducted by midwives and no deliveries were conducted by doctors; because the midwives conducting the deliveries were direct-entry trained midwives at the Associate Degree level rather than nurse-midwives or physicians with advanced degrees; because the majority of patient care, including the "catching" of babies, also  involved student midwives under supervision of Licensed Midwives or Certified Professional Midwives; because the deliveries were all conducted out of hospital; and because the staff had access to only simple technology -- on site we did not have lab capability, ICU or NICU capability, or surgical capability. In addition to that, and maybe most important to this study being unique, the mothers were demographically high risk. (Penwell 2005)

 

Elizabeth said that such results would be expected based on the fairly universally held belief that doctor-attended hospital births would be safer than midwife-attended births in an out-of-hospital setting, especially for high risk women living in poverty. By the time I finished this research and my thesis, our number of deliveries had increased to more than 12,000 in the slums of the Philippines, all of them free of charge to women who would be considered the poorest of the poor. I knew that we were having good outcomes, so I balked at Elizabeth's suggestion, but now I am so glad I did write my hypothesis the way she suggested, because in proving this hypothesis wrong, a model that works has been revealed in an unlikely place.

 

WHAT WORKS AND WHAT DOESN’T

Based on my own research and my 27 years of international midwifery experience, I firmly believe that the model that works (and will work anywhere in the world, under any conditions) is this: When birth is normal, nothing should be done to interfere; even seemingly small interruptions of the natural process can and often do cause pathology and a domino effect of complications. Conversely, if a labor becomes abnormal, everything possible should be done to correct the problem, quickly and efficiently in the setting in which the birth is occurring. This means midwives must be trained and equipped to carry out many medical interventions that are often thought to be the domain of physicians only. All birthing women, regardless of ability to pay, should have a trained birth attendant close to where they live, and those midwives should be trained in advanced life-saving skills, as well as being taught to respect the normal physiological process of parturition. Women and babies should always be treated gently, kindly, and with utmost respect. 

It is really so simple: reduce interventions in the normal physiological and social process of birth, be prepared to perform advanced emergency life-saving skills in the event of an emergency, and be nice.  In my opinion, many midwives I have observed do too much fiddling during normal birth and are not trained or allowed to do enough in the event of a life-threatening obstetric emergency. Unfortunately, kindness and compassion are too often ignored during the delivery of maternity care both in developing and developed countries. The North American midwifery model of care, as described by the Citizens for Midwifery (see cfmidwifery.org/mmoc/) has something important to offer the entire world.

In writing about a model that works, it is first necessary to describe the current model forced on most poor women worldwide.  Hospitals and government-run birth centers that serve the poor are too often inadequately funded and understaffed, resulting in sub-standard care. In addition, the abuses that occur on a regular basis to women giving birth are not often discussed, although in recent years the World Health Organization and the United Nations have begun to mention the problem of rude and culturally insensitive maternity care. (See www.safemotherhood.org/smpriorities/index.html.) From my years of traveling the globe as a midwife, observing births in many cultures on several continents and in dozens of countries, I am convinced that the problem is two-fold:

(1) Midwives are being largely trained by doctors, or at least influenced heavily by a medical model of intervention, so normal birth is being seriously compromised. This is especially true in developing nations where you see midwives, even at home births, forcing mothers onto their backs for delivery, performing numerous vaginal exams, shoving the baby out with fundal pressure, cutting episiotomies, and separating the newborn and mother at birth. Rough treatment and practices that rob dignity from the mother giving birth are the norm, rather than the exception, even within the practice of midwifery.

(2) Midwives are not prepared with the necessary skills or resources for obstetric emergencies; the midwives I have witnessed working around the world often do not carry a full range oxytocic drugs, IV fluid, suction or resuscitation equipment such as delees and ambu bags, or vacuum extractors for a second stage obstructed labor or fetal distress. Nor have they been trained in manual removal of placentas or neonatal resuscitation. Furthermore, very often they have not been taught the principles of uterine massage and immediate breastfeeding to prevent postpartum hemorrhage, or basic hygiene and the importance of sterile technique after rupture of membranes, during cord cutting, and while suturing the perineum.

According to the WHO 2005 World Health Report, the world’s greatest current health need is making motherhood safe and saving the lives of newborns.  The WHO 2005 report goes even further by stating that the health care professional needed most to save the lives of the mothers and babies is the midwife—especially the midwife who is trained to work outside of hospitals.  

Childbirth in much of the world is a study in contrast. On the one hand, it is a time of joy and celebration of new life. Yet for far too many families in worldwide, it becomes a nightmare that ends in death or permanent disability. Well over half a million women die each year attempting to give birth, with the vast majority of all maternal death occurring in Africa and Asia. For every one woman who dies during pregnancy or childbirth, 100 more women experience morbidity, often resulting in a life-long disability. Newborns that die within the first few days of life account for 37% of all deaths among children under five years old.   

The Philippines is a land of contrast as well. On the one hand, it is a beautiful tropical archipelago of more than 7,100 islands populated by warm, friendly people. Yet it is also a land of severe poverty and deprivation, where many families live in squatter huts without sanitation or clean water sources, and the minimum wage for a laborer is the equivalent of between US $1.00 and $2.00 per day. Philippine national statistics show that, on average, 11 mothers die of pregnancy and childbirth related causes every day, and a newborn baby dies every twelve minutes*³

The World Health Organization understands the need for midwives. In order to save the lives of the mothers and babies now being lost, not only do midwives need to be utilized, they need to be trained to work under a model that respects women and the process of normal birth, and respects the fact that normal birth can suddenly and without warning turn into a life-threatening emergency. Midwives can and must be trained to protect the normalcy of birth while being ready for and equipped to jump into any possible emergency with skills and tools necessary to save lives. In Priorities for Safe Motherhood, WHO reinforced its stand that all maternity care should be delivered if possible in midwife-run facilities, provided close to the woman's home and with her cultural values identified and respected (see www.safemotherhood.org/smpriorities/index.html).

I first read about the Safe Motherhood Initiative*⁴ in the late 1980s, soon after WHO began to track the tragedy and the magnitude of maternal death.  At the time I was running a small non-profit freestanding birth center and home birth practice that I had established in Fairbanks, Alaska.  In 1990 I went on a medical mission trip with my church to Thailand, Laos, and the Philippines, and what I experienced there shattered me. I saw first hand the devastating effects of the lack of health care for women, or, in many cases, the wrong things being done to women, with disastrous results. On this visit, and countless times since, I have witnessed women being treated roughly while giving birth, I have realized to my horror that it is the dirty little secret of maternity care in the developing world that much physical and emotional abuse of patients takes place at the hands of those sworn to protect them. I personally have witnessed doctors, nurses and midwives punching, slapping and viciously pinching women in the face, thighs, or buttocks during a normal delivery. There are often overly rough vaginal exams before and after birth that make otherwise stoic women cry out in shock and pain and weep uncontrollably afterwards. I have witnessed verbal abuse of women and the common practice of blaming them when an outcome is bad. In one case a woman who presented with a fetal demise was told it was her fault because she was “so dirty and stupid.” Sometimes sexual remarks are directed at women in the form of crude jokes. I have seen women lying in large open rooms, ten or twelve delivery tables all out in the open, where it is normal practice after the baby has been taken to the nursery to leave the woman lying spread-eagle for an hour or more, genitals exposed, while male cleaning staff mop the floors around her and dozens of people come in and out.  I have seen fundal pressure exerted in second stage with such force that it cracked the birthing woman's ribs. I have witnessed utter disregard for hygiene and sterile technique, seeing many women put on delivery tables that were still bloody from the last patient, and leftover suture thread being reused on numerous women.  Rubber gloves are rinsed out and used again and again for vaginal exams, including on women who had ruptured membranes.

Hospitals for those below the poverty line often make do with inadequate facilities. Bathrooms are communal and in short supply, showers are cold water only with dipper and bucket, and cleanliness is not a high priority due to the extreme pressure on the staff to manage a patient load as high as 120 births in a 24 hour period. Open windows allow stray cats to come and go in the hospital, but no one chases them out because they catch the mice and rats that are also commonly seen in the hospital wards. Open unscreened windows also invite mosquitoes that carry malaria and dengue fever.

There is never an ambu bag or oxygen in the delivery room in the low resource hospitals in the Philippines where I have volunteered or transported patients. Sometimes they have an infant resuscitation bag in the NICU, but not in the delivery room, so resuscitation, if needed, is delayed. A few hospitals we transported to had only an adult size resuscitation bag and personnel had to pump it only partially to avoid exploding a newborn's tiny lungs.  Fetal heart tones are rarely if ever monitored in labor, even if the mother is in second stage an hour or more, and most hospitals for the poor have only a stethoscope for auscultating the fetus. After being removed from their mothers, newborn babies are put three or four together in small bassinettes, naked, waiting to be bathed, where they are exposed to cross-infection and cold stress. Mothers are put two or three together in single beds to recover postpartum. Depending on the hospital, they are lucky if there is a mattress, much less a sheet, on this bed. Much of this is unavoidable because resources are few, but it all contributes to the lack of safety for the mothers and babies (on several occasions Mercy In Action has donated Ambu bags, dopplers and other equipment to the labor and delivery ward of under-equipped hospitals).

Early on in my years of volunteering in the Philippines, I was in a rural government hospital one night, and I saw a baby born not breathing, who was set aside as dead. Incredulous that no one was doing anything, I pushed over to where the "stillborn" lay, and began to do mouth to mouth resuscitation and chest compressions. After just 20 seconds of CPR the baby came around and cried. The nurses were astonished. The doctor looked up from suturing the mother and said "Oh, it’s alive!"

Family members are sent outside the hospital to buy IV fluids, drugs, and even blood for a transfusion, while the patient can only hope they will be brought back in time. Often the relatives have to borrow from unscrupulous money lenders who prey on the poor to be able to afford the medications needed. One night I went all over the city of Manila trying to buy blood for a woman who had delivered and hemorrhaged. When I finally found the type needed, I literally carried it back and passed it through the door of the surgical suite. Other times I have donated my own blood, as have many of our midwives, because even if we have a different blood type from our patient, they will give her a free unit of her blood type in exchange for our donation.  

I have witnessed similar circumstances in numerous hospitals of the Philippines and during my travels to Laos, Thailand, Ecuador, Mexico, Guatemala and Nepal. Midwives I have trained have reported to me that they have seen the same situations I have just described in India, China and countries of Africa as well. Last year, I set up an opportunity for one of our midwife graduates, who was a registered nurse as well as a CPM, to work in a hospital in Tanzania. This is an excerpt from an email she sent me after her first shift:

 

I was completely unprepared for what I saw.  I went in to working there with the attitude to serve and be helpful, not be a white woman know-it-all.  Oh Vic, it was brutal.  That's the word that best describes the whole experience.  The horrible fundal pressure (done with great intensity like chest compressions, just downward), pinching the woman's legs when she would try to close them, trying to insert a very non-sterile catheter, the midwife sticking her fingers in the woman's rectum to try to speed delivery and then sticking those same fingers into the woman's vagina, cutting a big mediolateral episiotomy, digging into the woman's vagina and into the uterus after the placenta was out to remove anything that might be left in there though the placenta was complete. Oh my heart broke! (Martin 2006)

 

 This is the care many resource-poor women are receiving, and it is not a model that is working, as evidenced by the horrific maternal and newborn mortality rates being recorded in Asia, Africa, and some countries in Latin America. The maternity system in most developing nations is badly flawed, a result of not enough funding, inadequate facilities and supplies, corruption that diverts funds meant for health care, over-worked and burned-out doctors, residents, and midwives, the influence of Western medical care that seems to be taken from the 1940s and 1950s, and a general culture of disregard for women and the disadvantaged.

In the Philippines, over half of all births in the nation still occur at home, but in many cases the homebirths being conducted are also lacking in safe, evidence-based practice. In the areas of the Philippines where I have worked, on Mindanao, Cebu, Luzon, and Mindoro Islands, traditional birth attendants also utilize fundal pressure to speed birth, often beginning early in labor before full dilation has occurred. Basics of cleanliness are ignored, and newborn babies are often left unattended on the floor until after the placenta has delivered, resulting in cold stress that can lead to death.  Even at home, the baby is often separated from the mother for hours while it is bathed and dressed. The woman is not necessarily encouraged to breastfeed until her milk has come in on the third day. By that time, bottle-feeding may already be established. Neither TBAs nor Licensed Midwives in the Philippines are trained in neonatal resuscitation for the newborn. Only rarely do they carry the proper combination of oxytocic drugs to control a serious hemorrhage.

 

CREATING MERCY IN ACTION

In light of this great tragedy involving pregnant women and infants, and in light of the global shortage of trained midwives as reported by WHO, I felt strongly that I could no longer concentrate solely on maternity care in America. In 1991, along with my husband Scott and family members, colleagues and friends, we conceived the idea to start teaching birth centers offering no-cost care in low resource areas in the Philippines.  In addition to the Philippines, we simultaneously established a prenatal clinic in Mexico and helped other doctors, nurses and midwives establish outreaches to pregnant women in various countries.

At the same time I began a life of travel to teach maternity care to groups that were sending primary health care workers on missions to the third world, such as Youth With A Mission, Heart For The World, and numerous churches around the United States. We founded Mercy In Action, Inc. as a charitable nonprofit organization that establishes, funds and operates birth centers and medical missions, and trains other midwives to do the same all over the world.

One of the first steps was to research how to set up a non-profit corporation, known as a 501(c)(3), with the US federal government. I checked out books from the library and consulted with a friend who was an attorney. In the end, I just followed the advice from the books and used the sample forms to begin the process, which took about a year to complete. We assigned a board of three, a Minister, a Certified Public Accountant, and myself, and utilized an advisory board of medical and legal friends. From that point on, I began to solicit donations from family and friends for the purpose of helping women in childbirth in low-resource countries. Some of my early donors, many of whom have remained staunch supporters to this day, are my former midwifery clients from my first 13 years in private home birth practice in Alaska. Upon hearing my stories, they embraced the moral responsibility to help other women in less fortunate circumstances to have good and safe births, and readily joined the cause with their financial support.  Our fundraising has always been grassroots and based on relationships. We have no mailing lists or glossy brochures, no television ads or mass marketing. We depend on God to provide by nudging people to share what they have with the less fortunate.

I try to accept requests to speak in churches, schools, or service organizations whenever asked, as I am passionate to share the needs of women around the world with people who for the most part are unaware. I have always felt that if people only knew the terrible plight of women and children in the world, they would care, and respond in some way. Occasionally a donation or ongoing pledge for support will come to us through my speaking and teaching, but I am just as happy if the group decides to start their own project. Last year I was honored with a "Making a Difference for Women" award from the Soroptimist club, and with that came a $1,000 donation to Mercy In Action. I take every opportunity to speak about Safe Motherhood and raise awareness and funds on behalf of the mothers we serve, and others like them.

The model we developed was to operate birth centers in the Philippines in which midwifery students could get their training while their tuition funds the operation of the center, providing a symbiotic situation wherein midwifery care can be given at no charge to the pregnant women. Private donations, occasional awards or grants, donations of supplies, and judicious budgeting have enabled us to do this work.  It is important that maternity care be free if we are to reduce maternal and neonatal mortality. Since birth is a normal process and usually requires no medical intervention, poor families will gamble on not needing a birth attendant (and not going for prenatal care) if they are unable to afford the fees associated with that care. However, since complications can occur suddenly, a trained birth attendant needs to be at each delivery. Maternity care is the one area of health care that should be subsidized so that all women can have equal access.

Salaries have been paid to staff in different ways. The director and clerical staff are given a set salary by the board of directors of Mercy In Action, based on need and operating budget. Staff midwives from the Philippines are given a monthly salary based on a scale slightly above the average wages for a midwife, and they are provided with housing as well. Volunteer foreign midwives serving as missionaries in the Philippines raise monetary support paid monthly in the form of a salary from their church. As founder and director, it is my full time job to fundraise for the needs of the mission, and when money is designated for me personally, this money is deposited into the general fund.  The board of directors set an annual salary, or stipend, for my own family's living needs. This has fluctuated over the years, from below the poverty line at times to somewhere around a reasonable salary for a midwife in the USA with a small private practice. During particularly lean times when donations are down, as happens occasionally when there is general nervousness about the economy, I have voluntarily asked the board to reduce my salary. Always it has been our goal to first pay for the health care projects we are funding overseas. My husband has for many years worked another job on top of his administrative duties with Mercy In Action, so that we could raise our children and help them with college. At this point, our children are all grown, and we live full time in the Philippines where neither of us, as foreigners, can work for wages. We are currently scaling back our training of North American midwives in order to concentrate on training TBAs and national midwives in the Philippines and other Asian countries, so we are more dependent on donations to continue this work than ever before.

Over the years during which we have trained midwife students, we have been committed to keeping our tuition costs low while still providing an excellent learning environment.  Unlike most colleges that raise their tuition each year, the midwifery tuition we have charged over the years has not significantly increased. According to the Trends in College Pricing Report 2006 (see collegeboard.com), college tuitions have gone up 35% in the past five years. Mercy In Action tuition has increased only 12% in 12 years. In 1995 when we began the projects in the Philippines, our tuition was US $12,500. In 2007 the charge is US$14,000 and there has been no increase in the past five years, even though our costs have risen both in overhead and in fees we pay on the student's behalf to the National College of Midwifery. This tuition pays for a two-year-equivalent study program, culminating in qualifying to take the North American Registry of Midwives (NARM) exam to earn the Certified Professional Midwife (CPM) credential (see chapter 17), and being awarded an Accredited Associate of Science Degree in Midwifery from the National College of Midwifery (see chapter 10).

Once we knew where the funding would come from--private donations, church donations and midwifery student tuition--it was a matter of finding a suitable place to build the first birth center of our own in the Philippines. In 1992 I had taken over the running of a birth center in Manila from a Canadian missionary family that was going home on furlough for one year (Penwell 1994a). Before that I had been involved in a small church project in a northern province of Luzon. The clinic project was temporary but it gave me a good idea of what was needed to gather and educate pregnant women from a poor area. Running Gentle Hands Ministry (and doing all the fund raising for one year to keep it going) gave me hands-on experience not only in high-risk births, of which we had many, but also in the day-to-day operation of a birth center in the Philippines.

That experience taught me that the need was great for affordable maternity care in the Philippines, and that kind, charitable midwifery care was welcomed and appreciated.

When we contemplated that first birth center, the question on all our minds was where to begin. The need was great everywhere.  I felt a strong inclination to begin in Davao City, on the southernmost island of Mindanao. I knew no one on that island, and in fact many people, both Filipinos and Westerners, were frightened of Mindanao because of the troubles there were, and still are, with Muslim terrorists and insurgents on that island. But the prompting in my spirit was strong, so I contacted a friend in Australia who knew missionaries in Davao, and, when asked to do so, they showed us the poorest slum area in Davao and introduced us around. We located a building to rent (a much wiser option for non-citizens) and began. Unlike setting up a hospital, the furnishings and equipment needed for a birth center are relatively simple; not much more than a few beds, a kitchen area, and a large meeting room for classes. The birth equipment needed is no different from a homebirth kit with the exception of trading a portable oxygen tank for a large stand-up oxygen tank. Due to the high risk nature of our practice, and according to guidelines written up by the International Confederation of Midwives and WHO, we also stocked our birth center with advanced life saving equipment: a vacuum extractor for prolonged labor or fetal distress, IV fluids, needles and tubing for fluid replacement, delivery of IV antibiotics, and hemorrhage control, and a refrigerator set aside for anti-hemorrhage drugs and vaccines. 

To date we have established eight birth centers in the Philippines on four of the largest, most populated islands (Luzon, Cebu, Mindanao, and Mindoro). Three of these birth centers are currently being funded and overseen by myself through our organization, Mercy in Action. Three more are currently being run by former midwifery students who trained in those centers and later returned, and two have closed. With every birth center we founded in the Philippines, we started by recruiting national Licensed Midwives to work for us on the project. These nationally trained and licensed midwives have been the backbone of every birth center, and have been present at every birth, bridging the gap between the foreign volunteer midwives and the patients. Our success in the Philippines was facilitated by the fact that English is an official national language, so it was easy for us to communicate. The initial stages of our work were also facilitated by the fact that the law governing the practice of midwifery in the Philippines exempts midwives who do not charge for their services, as is the case with us, so as humanitarian workers within the country we did not have to be licensed. However, in recent years this exemption has been called into question. Now we make sure that an experienced nationally licensed midwife or doctor is in charge of each clinic, and Westerners play a more behind-the-scenes role.

On February 8, 1996, a 34-year-old Filipina woman named Bebe came with her husband into our first fledgling birth center in Davao City on Mindanao Island and delivered a baby boy, the first of many thousands more babies we would eventually deliver at no charge to the parents. In 1998 we began another birth center in Cebu City on Cebu Island. In 2003 we began a small birth center in Kalinga Province among tribal women, and in 2004 we began a birth center in a large urban slum of Manila, both of these on Luzon Island. This year our newest effort is a pilot project to combine our Mother-Friendly/Baby-Friendly birth center model with an existing primary health care clinic in a rural area of Mindoro Island. Midwives will conduct all normal deliveries, and the clinic doctor will be consulted for complicated cases. This will combine the best of midwifery care with the safety of good medical back up, since we are over 2 hours away from a hospital here in Mindoro. Besides having delivered more than 12, 000 babies (as of December  2006), midwives in our birth centers have trained hundreds of midwifery and primary health care students to date, and the work described here continues.

 

HOW THE MODEL WORKS

The mission of the midwives of Mercy In Action is to reduce maternal and infant risk, and to protect and defend the dignity of women, by demonstrating Christ's love, compassion and mercy in action. Let’s consider what this means to a woman giving birth in the Philippines. 

             Allow me to describe how a woman in labor is treated at a Mercy In Action Birth Center. Prenatal days are quite festive, with free nutritious food served to the pregnant patient and any family members she brought with her. Often there is music and singing. Later, an interactive health teaching is done in her language. Using the book Facts For Life published by UNICEF (see www.ffl.org), we explain the information every woman and family has a right to know about safe motherhood, child spacing, breastfeeding, child development, hygiene, immunizations, and HIV/AIDS prevention, among other topics. One by one, the patients are then called into a private area for their individual prenatal exam, which includes: blood pressure check, weight, the measuring of fundal height, auscultating the baby's heart rate, Leopold's maneuvers for determining fetal position, and determination of due date. In addition, dietary counseling is done, and if we have the resources, the patient is given a bottle of vitamins free of charge. All women are given a simple lab test for anemia, and this hematocrit test is done several times during pregnancy. When appropriate, according to Mercy In Action policies and procedures, the patient may be sent for an ultrasound, further and more detailed lab workup, or referral to a physician for assessment.  

            Vaccinations are also a part of our midwifery and primary health care services. Tetanus vaccinations are given to all pregnant women in developing countries to protect against neonatal tetanus; we give two shots per pregnancy, at approximately six and eight months of gestation. At times we have also given childhood immunizations. In the Philippines these vaccinations begin at birth with a BCG vaccination against tuberculosis. Later we give immunizations to protect our babies from polio, measles, diphtheria, tetanus, and whooping cough, all diseases that kill many babies and young children in developing countries.

When a woman arrives in labor, she is greeted warmly and shown to a bed made up with clean sheets over a waterproof mattress. Her bed is kept private by a system of curtains that completely enclose her into a private cubicle. A team of two or three midwives, at least one of whom is Filipina, assesses her. If determined to be in active labor without risk factors that would necessitate a hospital birth, she is checked in and given an informed consent form to sign. Her family members are welcomed to stay, and are offered water, coffee or other refreshment. The woman is allowed to wear her own dress, walk around the outside courtyard, interact freely with her partner and loved ones, and is offered water or juice on a regular basis. She can eat if she wishes. A clean bathroom with toilet, shower and sink is made available to her, and she is also instructed to urinate often. All procedures are explained to her, as well as instructions given on how to maximize contractions and how to minimize pain. Vital signs are monitored often but vaginal internal exams are kept to a strict minimum, ideally only a few during an entire labor. In pushing stage, the woman is offered her choice of positions, with upright being the preferred position for birth. The atmosphere during the delivery is kept calm and quiet, and the mother is supported and gently encouraged. As long as the baby is born in good condition, he or she is given to the mother to hold immediately after birth, thereby lessening trauma and stress to both mother and baby. The baby is put to the breast immediately, reducing the risk of excessive blood loss and ensuring bonding and successful breastfeeding, both known to be important to infant survival. Third and fourth stage are monitored closely for signs of hemorrhage or shock, and treated accordingly using any or all of the following: oxytocic drugs, IV fluids, oxygen, fundal massage or bi-manual compression, and urinary catherization.

At all times, cleanliness is paramount. One of the best ways we can prevent the spread of HIV/AIDS, sepsis, and other diseases is with careful attention to how we handle blood and body fluids during and after birth, and how clean we keep our hands and our surroundings. Clean, fresh gloves are worn for all appropriate situations. Instruments used for the births are sterilized in an autoclave. Sinks are available for frequent hand washing, and midwives are required to keep their fingernails short and free of polish.  Careful attention is given to sterile technique whenever it is called for, such as during suturing or following rupture of membranes. Floors, bathroom fixtures, and vinyl mattress covers are washed with soap and a chlorine solution between patients.

Mercy In Action midwives practice according to Mother-Friendly and Baby-Friendly practices as outlined in the "Mother-Friendly Childbirth Initiative" created by the US-based Coalition for Improving Maternity Services (CIMS) (see www.motherfriendly.org), and the WHO-UNICEF "Ten Steps of the Baby-Friendly Hospital Initiative (see www.unicef.org/programme/breastfeeding/baby.html). I find that by adhering to the tenets of Mother-Friendly and Baby Friendly care, we are giving the best care possible both from a medical and psychosocial standpoint. 

Mercy In Action midwives practice within a culture of shared knowledge, which includes sharing knowledge with student midwives and interns and with the patients and their families. We teach the women constantly through each prenatal visit, helping the mother to feel empowered by understanding her own vital signs, what is normal in position and growth charting of the baby, as well as how she can improve her chance for a good outcome through healthy nutrition. Our motto is that we should know nothing about the patient that she does not know about herself. Student midwives are included in everything, and have a wonderful opportunity to learn by observing and doing. There is a richness to the way we learn from each other, and from the patients themselves.  I have always said that my real teachers are the mothers and babies, and we want our students to realize and appreciate this fact.

Care given is based on kindness, gentleness, and compassion. It must be noted here that Mercy In Action is a Faith-based Christian ministry established on service and mercy, and all who work with Mercy In Action are consciously following the teachings of Jesus to care for the "least of these" as if they were in fact Christ himself (Holy Bible, Matthew 25:34-40). Routine maternity care includes prayer, and this prayer takes the form of staff praying in general for all patients who will come at the beginning of each prenatal day, prayer for a safe delivery at each birth, and a prayer of thanksgiving for each newborn baby. Each woman is asked if she would like a prayer said for her, and if she declines a verbal prayer, the midwives respect this; however, most patients do ask to be prayed for either during their prenatal exam or during labor.

             Most often the person presiding over the actual "catching" of the baby is a student under direct supervision of a Certified Professional Midwife or a Licensed Midwife. The Certified Professional Midwives in my study were all graduates of the National College of Midwifery (see chapter 10).  Licensed Midwives from the Philippines were graduates of a two-year direct-entry midwifery college within that country. Since the training system in the Philippines does not allow for much hands-on clinical experience, if the Filipino Licensed Midwives hired by Mercy In Action have limited experience they are paid by our organization for an additional year of hands-on training before they conduct deliveries without supervision. When student midwives are properly educated and trained, their involvement in actual patient care appears to be a benefit and not a liability. Our training of midwives from the Philippines and a variety of other countries helps us to achieve several important aspects of this model.

First, we are not just helping the women we deliver, but are training the next generation of midwives. According to WHO, the developing world needs at least 300,000 persons qualified to attend births in order to reach the Millennium Development Goal of a two-thirds reduction in maternal mortality by 2015.⁵* It has come to my attention recently that some midwives from the United States have speculated aloud that perhaps it is not in the best interest of Third-World women to have students "practicing" on them. Hopefully the excellent outcomes in this study, as well as the high level of personal satisfaction with their birth experiences expressed by the families, will put that concern to rest. Obviously those who have voiced this concern have no idea of the actual quality of patient care being given and the good outcomes achieved. Having student midwives present is seen as a plus by the women we serve, since there are always several pairs of hands and loving hearts to help them navigate the difficult waters of birth. In addition, it is relevant here to note that all centers of higher learning involved in the training of medical and/or nursing students utilize students in patient care in adjoining hospitals. If a life-threatening complication occurs, the senior midwife steps right in and guides the student or takes over altogether.

Second, also not unlike medical or nursing schools, the student tuition helps to fund the teaching facility and underwrite the free care given to indigent patients. This is certainly the case with Mercy In Action; families are not charged for midwifery services or for a facility fee at the Mercy In Action birth centers. Yet because the student tuition supplements private donations to fund the facility, the excellent care continues to be available to all, regardless of ability to pay (families are given a chance to make a donation to cover any medications used during the birth).  This is a model that could be used worldwide to alleviate the burden of cost of health care for the poor, while continuing to train much needed midwives to serve among them.

 Women and their families continually express gratitude to the midwives of Mercy In Action by verbal words of thanks, thank you letters and cards, frequent smiles, gifts, and even the common practice of naming their baby after one or more of the midwives involved in their care. I have often noted the beautiful smiles on the faces of our mothers and compare this to the stoic facial expression often seen in the hospital maternity wards.  Years ago I took a simple poll of 200 women who had delivered with us, and asked them the main reason they had chosen to give birth in our birth center. I thought the obvious answer would be that the care was free. However, less than 1% said that they came because it was free. The majority, over 66%, said they came because the midwives were kind. This shows me that the model that works is a model that considers the often overlooked aspect of kindness in offering maternity care.

 

DETAILS ON THE FIRST 7,565 MERCY IN ACTION BIRTHS

TABLES

 

Table 1.

Characteristics of Care provided to 7,565 women delivering in Mercy In Action birth centers in Davao and Cebu 1996-1999

Characteristics of Care Provided	No (%) of women receiving care (n=7,565)
Birth Attendants
Deliveries conducted by midwives	100%
Prenatal Care
Trimester prenatal care began
First trimester (1 to 3 months)	6%
Second trimester (4 to 6 months)	57%
Third trimester (7 to 9 months)	37%
Number of prenatal exams
1 to 5 exams	36%
6 to 9 exams	41%
> 10 exams	17%
Women receiving no prenatal care	6%
Deliveries
Spontaneous vaginal birth	95%
Position for birth
Birth stool (supported squat)	28%
Squatting	1%
Hands and Knees	1%
Semi-sitting	18%
Dorsal	50%
Side lying	2%
Mobility-1st stage
Walked around	86%
Stayed in bed	13%
Movement restricted for medical reason	1%
Mobility 2nd stage
Moved around, changed positions	33%
Stayed in one position	66%
Lacerations of the birth canal
No laceration of birth canal	49%
First degree laceration	31%
Second degree laceration	18%
Third degree laceration	1%
Fourth degree laceration	0.1%
Episiotomy	0.4%
Nulliparas
No laceration of birth canal	24%
First degree laceration	35%
Second degree laceration	38%
Third degree laceration	2%
Fourth degree laceration	0.2%
Episiotomy	0.3%
Multiparas
No laceration of birth canal	61%
First degree laceration	29%
Second degree laceration	9%
Third degree laceration	0.3%
Fourth degree laceration	0.08%
Episiotomy	0.4%
Compound presentation (arm alongside head)	5%
Persistent posterior presentation	4%
Face presentation	0.02%
Breech	0.5%
Babies
Birth weight
< 2500 grams (5 lbs, 8 oz)	10%
2501 to 3460 grams (5 lbs, 9 oz to 7 lbs, 10 oz)	79%
3461 to 4000 grams (7 lbs, 11 oz to 8 lbs, 13 oz)	11%
> 4000 grams (8 lbs, 14 oz)	.06%
Smallest birth weight   892 grams (1 lb, 15 oz)
Largest birth weight   4930 grams (10 lbs, 14 oz)
One minute APGAR of 7 or greater	92%
Breastfeeding
Breastfeeding at birth	99.8%
Bottle or NG tube	0.2%

 

Table 2. 

Complications and Interventions of 7,565 women delivering in Mercy In Action birth centers in Davao and Cebu, 1996-1999

 

Complications or Interventions	No (%) of women or babies experiencing complication or intervention (n=7,565)
Neonatal Complications
Meconium-stained amniotic fluid	33%
Light	13%
Moderate	12%
Thick	8%
Fetal distress during labor	25%
APGAR < 7 at one minute	8%
Infants requiring stimulation	17%
Infants requiring full resuscitation	3%
Low birth weight	10%
Newborns requiring transfer to hospital	2%
Neonatal mortality	0.5%
Maternal Complications
Postpartum hemorrhage > 500 cc	17%
Postpartum hemorrhage > 1000 cc	2%
Hypertension > 140/90	5%
Delivery requiring assistance (vacuum extractor)	2%
Delivery requiring manual assistance	3%
Shoulder dystocia	3%
Maternal mortality	0.05%
Interventions / Drugs
Postpartum use of oxytocin	33%
Postpartum use of methergine	9%
Suctioning of baby with deeLee mucous trap	33%
IV fluids in labor or postpartum	15%
Oxygen to newborn	12%
Vacuum extractor assisted delivery	2%
Maternal catheterization	2%
Infant resuscitation-PPV or CPR	3%
Manual removal of placenta	2%
Episiotomy	0.4%

 

What makes my study so unique is the fact that we did keep such detailed statistics on such a large population of women, from the moment we started the first birth center and including each and every woman who checked in for labor for the next 95 months.

The demographic statistics show that most of the pregnant women are unemployed (92%). Over a third (34%) of their spouses or partners are unemployed as well. For the men who held jobs, the average daily salary was US $2. Only a little over half of the women were legally married (54%), though being pregnant and alone was rare (6%). A common situation was for women to live with a man (40%), though that did not always afford security, as some men moved frequently between live-in situations, sometimes even keeping two families at the same time in different parts of town. It is not known how often domestic violence occurred among our patients, as the question was not asked on official forms, but we do know that it was present in a considerable number of cases. Teenagers accounted for 14% of our population, while only 7% were over 36 years old. The youngest mother was 13 years old; the oldest 52 years old. Multiparas accounted for 70% of the population, with 4% being grand-multiparas. The highest parity recorded was 12. The average number of children in the Philippines is 5 per family, with some stopping at 2 and others having 8-10 children or more.

More than half (57%) of the women first came seeking prenatal care in their second trimester. 37% began prenatal care in their third trimester, considered to be dangerously late. 6% of the women had sought no prenatal care at all, just showing up at our door in labor. Reflecting their late start in availing themselves of prenatal care, 42% of the women received fewer than six exams before birth. Delivery positions were suggested but not enforced, except in 1% of the cases for medical reasons, such as when the woman was asked to lie on her left side to reduce blood pressure. The vast majority (86%) of the women chose to walk during labor. 48% chose an upright position for delivery, and 52% chose to lie down or assume a semi-reclining position. 28% of the births occurred on a simple birth stool, usually with the husband supporting from behind.

Most women (79%) went into labor on their own and needed no augmentation, but in 21% of the cases, non-drug methods of induction or augmentation were used, such as nipple stimulation, castor oil or stripping the membranes. This was deemed necessary especially if the water had broken or the woman was post-dates. Minor or no lacerations of the birth canal occurred in 80% of the deliveries. Second-degree tears involving the perineal muscle and requiring stitches occurred 18% of the time, with more serious lacerations or episiotomy occurring in less than 2% of the cases. Women who had given birth previously had minor or no lacerations of the birth canal 90% of the time. 68% of the deliveries involved some perineal support or counter pressure to the emerging head, with 32% being what we call “hands off,” allowing the baby to emerge without hands touching the baby or perineum. This reflected differing philosophies among midwives, and did not seem to affect the overall rate of tearing.  [Editors’ note: At this time the RCT study by Leah Albers (2007) at the University of Mexico on reducing genital tract trauma is still not published, but it does confirm that supporting hands on the perineum and hot compresses neither harm nor protect genital areas from splitting or separating.] Some sort of manual assistance with the birth, such as forcefully stretching the vaginal opening, was used 3% of the time in difficult deliveries. A vacuum extractor suction device was used 2% of the time, for fetal distress or prolonged second stage (all the midwives and students are trained in its use, according to a joint recommendation by World Health Organization and the International Confederation of Midwives that midwives working in developing countries have advanced lifesaving skills).  Episiotomy was rare at 0.4% and was done for fetal distress only.

By far the largest number of babies arrived head-down, with 99.5% in a vertex position. 4% were born persistent posterior, and there were two face presentations during this study. Breech birth occurred at our center 0.5% during the study, for a total of 35 breech deliveries.  High-risk breech deliveries according to the breech scoring chart described by Rahima Baldwin and Valerie El Halta were referred to the hospital before labor, if there was time.

Pregnancies known to be premature, post-mature or complicated by hypertension were also referred out unless the labor was too far advanced. The majority of the babies (90%) were between 2501 grams (5 lbs, 9 oz) and 4000 grams (8 lbs, 13 oz). 10% were considered low birth weight at 2500 grams (5 1/2 lbs) or under. The smallest baby was 892 grams (just under 2 lbs), and the largest was 4930 grams (10 lbs, 14 oz).

Practically all (99.8%) of the babies were breastfed at birth. At the parents’ request, 97% of the babies received Ilotycin eye ointment, and 73% received vitamin K.  Neonatal complications included meconium-stained amniotic fluid, with moderate to thick staining being present 20% of the time. Fetal distress occurred 25% of the time to varying degrees, but only 8% of the newborns had an Apgar score of less than 7 at one minute following birth. 20% of the babies required some stimulation or blow-by oxygen, while only 3% required positive pressure ventilation (PPV) or cardiopulmonary resuscitation (CPR). 2% of the newborns were transferred for hospital care at some time following birth. These mothers or babies who transferred to a hospital were followed up with a midwife visit and were included in the study.

Maternal complications included hemorrhage, shoulder dystocia and placenta problems. Although many texts now define hemorrhage as blood loss over 1000 cc, because the women in this study were malnourished and often anemic, I chose to use the more conservative definition of hemorrhage as blood loss of 500 cc or greater. By that definition, 17% of the mothers suffered a hemorrhage; however, only 2% had hemorrhages defined by blood loss greater than 1000 cc. Intravenous fluids were given in 15% of the cases, oxytocin in 33% and methergine in another 9%. Because of the high number of cases in which the placenta partially separated with accompanying bleeding, the placenta was assisted to deliver with gentle controlled cord traction in half of all cases (54%), and manual removal of the placenta was required in 0.2% of all deliveries.  

Maternal catheterization was required 2% of the time. Shoulder dystocia happened in 3% of the cases.

Transfers to a hospital after admission to the birth center due to maternal factors occurred in 5% of the cases. The intrapartum transport rate was only 3.5%, and less than half of these transports resulted in caesarean section births, for a cesarean rate under 2% (these were women who had already been screened as suitable for an out-of-hospital birth by the Mercy In Action midwife team, according to our own internal protocols).  When a woman or baby was transported to a hospital, a midwife accompanied her and turned over pertinent data to the attending physician. Rarely were Mercy In Action midwives allowed in the delivery room once we arrived at the hospital, but it was our practice to visit the woman later in the hospital or at home if at all possible, and record the outcome and any interventions on her chart. This data was included in the study.

Neonatal mortality was 0.5%, but it might have been higher, since not all parents brought their babies for follow-up exams through six weeks. The deaths recorded did not occur while in our facility, with the exception of stillbirths, but rather the babies died some hours or days later in the hospital where we had transported them, or after being discharged back home. Many complicating factors surrounded neonatal deaths due to the poverty of the parents and the lack of access to medical care for many. Even after transporting to the hospital a baby who was having respiratory problems, the parents were often not able to afford a respirator, or an incubator may not have been available for a premature baby.  Some babies died weeks after birth from unhealthy conditions in their homes. Since autopsies are not done in the Philippines when a baby dies, it is impossible to ascertain the true cause of death. Sepsis and birth defects were the most commonly named causes on death certificates.

Maternal mortality, defined as a death within 42 days of giving birth, happened four times, for a statistic of 0.05% of births. In all cases the mother had checked out of the birth center, and only later was it reported back to the midwives that she had died. In one of the four cases, a woman arrived as a "drop in" (our name for a patient we had never seen for prenatal care) in advanced labor, obviously very ill. She refused transport to a hospital, went home the next day, and died two days later of tuberculosis, a common ailment in the Philippines that according to her family she had been diagnosed with previously.  The second reported maternal death was a woman who checked out healthy but went to a local “healer” and received a massage rubdown with a gasoline and kerosene mixture, only to die days later in the hospital of full-body chemical burns. Neither of these cases had anything to do with where the woman gave birth or the quality of maternity care. In the remaining two cases, it was reported to us that a postpartum patient had died weeks later, one from supposed infection and one of unknown etiology.

The problem of possible under-reporting in our statistics is the same for the Philippines as a whole. Experts tracking maternal and neonatal death postulate that the published rate of neonatal and maternal mortality is definitely under-reported all across the developing world. Even in the USA the rates of maternal mortality are said to be grossly under-reported (see OB/Gyn News, January 11, 2000). The Centers for Disease Control and Prevention (CDC) warned in 1998 that "the actual number of maternal deaths in the United States is estimated to be 1.3 to three times that reported in vital statistics records." The World Health Organization warns that "cross country comparisons should be treated with considerable circumspection because different strategies have been used to derive the estimates for different countries, making it difficult to draw comparisons (see Maternal Mortality in 2000: Estimates Developed by WHO, UNICEF, UNFPA).

All in all, this study suggests that demographically high risk women (anemic, malnourished, physically abused, unmarried and impoverished) can still have good outcomes using a model of Mother-Friendly and Baby-Friendly care run by midwives in an out of hospital setting in a poor and under-developed country such as the Philippines.  

 

TRIALS AND TRIUMPHS

The birth centers described here offer a model that  provides excellent midwifery care, as well as love, comfort and support to women and their families during pregnancy, birth and postpartum. Few types of maternal/child health services available are as appreciated by the Filipino people as these Mercy In Action freestanding charity birth centers. Here people are welcomed and loved, regardless of their circumstances. Here they find the values of home birth they are used to, but in a cleaner, more spacious setting than their own homes. In the birth center they find the skilled midwives, emergency medicines and equipment that make birth safe, without sacrificing the comfort, kindness and personal care they crave.

Still, not all of the birth centers we started since our inception are in operation today. Over the years we have faced turnovers, staffing shortages, disagreements over management styles and conflict over whether or not students should be part of the team. We have been awarded Model Clinic status and also been issued a cease and desist order, both coming from the Department of Health of the Philippines. In one recent instance, we faced unavoidable and overwhelming opposition to one of our birth centers. The cease and desist order closed a busy and successful birth center we ran in Manila, and only later did we learn it was because we were seen as competition to doctors who sat on our licensing board and owned their own for-profit birth centers in the area. These situations of government corruption are disheartening, to say the least, when you are in a country faced with so much need.

Some opposition we were able to overcome by complying with new regulations, like the new law a few years back requiring licensing for all birth centers. We got a copy of the regulations, and went out and purchased all the things they required (for instance, the stirrups for the end of our birthing bed that we were required to have but never used). Other times, we would call meetings with the doctors at the local hospital and ask to be included in peer review. This went a long way toward defusing any animosity over transports we had brought to them. At times over the years, opposition took the form of workers in the mission having clashing viewpoints about how to do things, or about how students fit in the organization. There was a constant tension between the needs of the birthing women, the needs of the student midwives, and the needs of the supervising midwives. When things were running according to plan, these needs were symbiotic; but the world is not perfect and even the best intentioned humanitarians are flawed human beings, so conflict arose at times. The one thing I found most disheartening was when other American midwives, who had themselves been trained by us in the apprenticeship model, did not seem to value the young students on our team the same way I did. Over this issue, Mercy In Action turned over two different birth centers we had founded and invested in for years, in order to allow the clinics to continue to operate for the communities' sake without interpersonal friction. In one case, the birth center eventually closed down, but another was later established in its place by a former student who hired the same staff of Filipina midwives. In the other case, the new directors eventually started their own midwifery training school, which is successful to this day.

What I value most is that poor women would be helped and served by trained and compassionate midwives, whether or not we agreed on exactly how to go about providing that service.

Young North American midwives who have stepped into leadership roles in these birth centers have found it both a joyous experience of a lifetime, and a stress beyond anything they could have imagined. A few have even had to seek counseling for post-traumatic stress disorder following their time on staff with Mercy In Action in the Philippines. To understand the high burn-out factor, consider that these clinics were often delivering 80 to 100 babies each month, and seeing approximately 40 women per day for prenatal care. All that on top of regular home visits, follow up with labs and hospitals, and teaching of students. Midwives and students were often witness to heartbreaking scenes of wife or child abuse, abject poverty, corruption and alarming injustice issues. Part of the stress was in feeling powerless to change these situations.  It is also important to note that while our outcomes are excellent in terms of overall mortality, it is overwhelming for a midwife to experience even one mother or infant death. Even when we save lives, the constant battle against injustice, the constant fight for life, is soul-wearying: the average volunteer midwife lasts only 2 years. Westerners coming over tend to have little experience in dealing with death and thus no conceptual grid for coping with the reality. The following is an excerpt from one young midwife's journal entry shared here with permission, about her time with Mercy In Action. 

The things of this time will haunt me for the rest of my life, and for that I am grateful. I am only 24 years old and I have felt the weight of the world on my shoulders. I have fought to save the life of a newborn and lost. I have held a dead infant in my arms and sobbed over the loss of her life. I have put my fingers inside a lifeless little hand and prayed that she would grasp it--knowing that she never would. I will never forget the feel of her silky hair as I cut off a lock for her parents, or the sound of her mother's anguished cries as we handed her a tiny bundle, dressed in Winnie-the-pooh. I have slid down a wall, pulled my knees to my chest, and wished that I was dead. I have fought to save the life of a newborn and won. I have forced air into tiny lungs- seeing her skin turn pink, and her limbs flex. I have rejoiced at seeing her lower lip quiver as she gathers her strength to scream in protest. I have wrapped her up and given her to her mother who reached out for her child, crying with relief. I have fallen to my knees in gratitude, knowing that this life could have easily been taken. (Osborne 1998 )

 

We have found that even when North American midwives are not able to handle, on a long term basis, the painful things they see and the intense working conditions, they are changed for the better. The young woman who wrote this essay in 1998 eventually went on to Afghanistan to train midwives with the organization Samaritans Purse, and later served as a midwife in Darfur with Doctors Without Borders. She is now in medical school with plans to become an obstetrician, determined to return to the Third World with even more skills to help the less fortunate. This basic altruism that comes from awareness of the acute needs of the world is a common denominator among graduates of the Mercy In Action midwifery training.

In staffing these birth centers, we have now increasingly turned over responsibility for leading to Filipina midwives, and for help on staff we depend on short-term volunteers and interns, both Filipino and foreign. We have this past year begun another new model, working with a Filipino doctor to make available maternity services within his existing rural health clinics.

 

CONCLUSIONS

 

Through all of our victories and defeats, I do believe we have found a model that works. This type of provision of maternity care is innovative, cost-effective, and evidence based. The environment, the facility, the providers and their level of education, all appear to be beneficial on many levels.  Maternal and neonatal mortality rates are significantly lower than in the country as a whole; families appear happy and well-pleased with their birth experience; and this type of natural birth philosophy, combined with advanced life-saving skills on the part of the midwives, reduces mortality and morbidity that come from both too much or not enough intervention. In addition, this model of care encourages early and successful breastfeeding, which has been shown to an important factor in reduction of under-five year old death rates in the developing world.

As the whole world strives to achieve the United Nations Millennium Goals (www.un.org/millenniumgoals/) by the year 2015, let it be noted here in conclusion that five of the eight goals are being directly addressed by the work of Mercy In Action midwives: to eradicate extreme poverty and hunger, to promote gender equality and empower women, to reduce child mortality, to improve maternal health, and to combat HIV/AIDS and other disease through prevention and immunizations. These are lofty goals, but ones that are attainable using birth models that work.

 

Vicki Penwell doing a newborn exam on a small patient in the Philippines.

Photo by Cathee Pullis

 

 

Children at birth. Photo by Vicki Penwell.

Endnotes

1. Certified Professional Midwife, (CPM) a designation granted by North American Registry of Midwives (NARM). www.narm.org

 

2. Licensed Midwives from both the Philippines and the United States. Vicki Penwell holds a license from the state of New Mexico and the Certified Professional Midwife designation from North American Registry of Midwives. For other examples of her work, see Penwell 1991, 1994 a,b, 1995, 1998, 2001, 2004, 2005a,b.

 

3. See www.unicef.org/pon96/leag1wom.htm, www.who.int/countries/phl/en/, www.childinfo.org/mics/mics3/docs/dissemination/DHS_Philippines_infant_and_child%20mortality.pdf, www.unicef.org/Philippines/children/ch_2.html

 

4. See Priorities for Safe Motherhood www.safemotherhood.org/smpriorities/index.html

 

5. See Shortage of midwives responsible for thousands of deaths: WHO http://gn.rti.org/news/index.cfm?id=92&fuseaction=detail).

 

 

References

Albers, Leah.  2007.  Address at the American College of Nurse Midwives on Reducing Genital Tract Trauma at Birth.  Chicago Sheratan Hotel.

 

Johnson L and and Daviss BA. 2005. Outcomes of planned home births with Certified Professional Midwives: Large prospective study in North America. British Medical Journal 330(7505):1416. Available at  www.bmj.com/cgi/content/full/330/7505/1416

 

Martin, Christy. 2006} Unpublished private correspondence with the author, used by permission.

Osborne, Amy. 1998} Unpublished journal entry, used by permission.

Penwell, Vicki. 1991. “Midwifery Education: A Global Perspective.” Midwifery Today 20. Winter

--1994a. “Gentle Hands Across Manila.”  Midwifery Today  #30 Summer Reprinted in MIDIRS journal

--1994b.  “Cross-Cultural Childbirth Education.”  International Journal of Childbirth  9(2). May

 

--1995. Down Mercy Road. Self-published book.

--1998. “Midwifery Education: A Global Perspective.” In Paths to Becoming a Midwife, eds. Jan Tritten and Joel Southern. Eugene OR: Midwifery Today.

--2001. “Philippines: In the Night Lorega.” Midwifery Today 58.  Summer

2001--“Mercy In Action: Training Missionary Midwives to Serve the Poor.” Midwifery Today. #60 Winter

--2004. “Mercy In Action Philippine Birth Center Statistics.” Midwifery Today  #70 Summer

--2005a. Mercy In Action: Philippine Birth Center Statistics Abstract for Master's of Science in Midwifery Thesis, National College of Midwifery.

--2005b. Mercy In Action: Philippine Birth Center Statistics for Master's of Science in Midwifery Thesis National College of Midwifery.

 

Ronsmans C, S. Holtz, C. Stanton. 2006. Socioeconomic differentials in caesarean rates in developing countries: a retrospective analysis. The Lancet 368 (9546): 1516-1523.

World Health Organization. 2005. World Health Report. www.who.int/whr/2005/en/index.ht