Mercy In Action
Philippine Birth Center Statistics
By Vicki Penwell
Abstract: I studied 7,565 women admitted for labor and delivery in two free-standing charity birth centers that I established in the Philippines, one on Mindanao island and one on Cebu island. The births occurred between February 8, 1996 and December 31, 2003. Midwives conducted all of the deliveries that occurred in the birth centers. The midwives were Certified Professional Midwives (CPM), or Licensed Midwives (LM) from the USA, Canada, and the Philippines. The midwives were supervising student midwives enrolled in the Mercy In Action College of Midwifery & Primary Health Care, and dual enrolled in the National College of Midwifery’s ASM program.
The women were at higher than average risk of a poor outcome of pregnancy, because of demographic risk factors; most of the women were poor, often malnourished, and lived in crowded urban slum conditions. Ninety-two percent of the women and 34% of their spouses were unemployed, and only a little over half were married.
In spite of the poverty, 95% of the women had spontaneous vaginal birth; 83% had blood loss less than 500ml; 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 occurred 7% of the time, with half being before the delivery, and half after delivery. Neonatal mortality was 4.1 per 1000.
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 poor parts of the world, it can become a nightmare. Well over half a million women die attempting to give birth, with 99% of all maternal death occurring in the third world; yet most of these tragedies could be prevented with simple midwifery care.
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, with warm, friendly people. Yet it is a land of severe poverty and depravation as well, where many families live in squatter huts without sanitation or clean water sources, and the minimum wage for a laborer for a full day of work is the equivalent of US$2. Philippine national statistics show that, on average, one mother dies of pregnancy and childbirth related causes every 6 hours, and a newborn baby dies every 5 minutes.
According to World Health Organization (WHO), the Safe Motherhood Initiative, or in other words, making motherhood safe, is the world’s greatest current health need. WHO goes even further by stating that the health care professional needed most to save the lives of the mothers and babies is the midwife, and especially the midwife who is trained to work outside of hospitals. In light of this, I, along with many family members, colleagues and supporters, conceived of the idea to start “teaching birth centers” in the Philippines. In this setting we founded Mercy In Action, a non-profit 501(c)(3) Christian organization that sets up clinics in the third world for two purposes: (1) to help make pregnancy and birth safe for the poor women who can not afford medical care, and (2) to train missionary midwife students in order for them to start other charity birth centers among the poor in the developing world.
On February 8, 1996, a 34-year-old Filipina woman named Bebe walked into our first fledgling birth center and delivered a healthy boy, the first of many thousands more to come! In 1998 we began another birth center on a different island, and this year, 2004, we have begun our third birth center on a third island. Besides having cared for 7,656 women and babies, 95 missionary midwife students have been trained in the birth centers to date, and the work described here continues on.
A demographic look at our statistics shows that most of our pregnant women are unemployed (92%). Over a third (34%) of their spouses or partners are unemployed as well. For the men who do work, the average salary for a day’s work is US$2. Only a little over half of the women were legally married (54%), though being pregnant and single was rare (6%). A common situation was for women to live in with a man (40%), though that did not always afford security, as some men moved frequently between live-in situations and may even keep two families at the same time in different parts of town. Teenagers accounted for 14% of our population, with 7% being over 36 years old. The youngest mother was 13; the oldest 52. Multipara’s accounted for 70% of the population, with 4% being grand-multiparas. The highest parity was 12.
More than half (57%) of the women came to us seeking prenatal care for the first time in their second trimester. Thirty-seven percent began in their third trimester, considered to be dangerously late; however, 6% of the women we delivered 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 less than 6 exams before birth.
Delivering positions were suggested but not enforced, except in 1% of the cases for medical reasons. The vast majority (86%) of the women chose to walk during labor. 48% of the women chose an upright position for the delivery, and 52% chose to lie down in bed for delivery. Squatting, hands and knees, or side lying were not popular positions, accounting for only 4 percent of total deliveries. Women did like to use the simple hand carved birth stool (28%), which put them in a squat-like position for birth. Most women (79%) went into labor on their own and needed no augmentation, but in 21% of the cases, natural induction or augmentation methods were used, such as nipple stimulation, castor oil, or stripping the membranes.
There were minor or no lacerations of the birth canal in 80% of the deliveries. Second-degree tears involving the perineal muscle occurred 18% of the time, with more serious lacerations or episiotomy occurring less than 2%. Women who had given birth previously had minor or no lacerations of the birth canal 90% of the time. Sixty-eight percent of the deliveries involved some perineal support or counter pressure to the emerging head, with 32% being totally hands off. This reflected differing philosophies among midwives, and did not seem to affect the overall rate of tearing. 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 devise was used 2% of the time, for fetal distress or prolonged second stage (all our midwives and students are trained in its use, according to World Health Organization’s recommendations for advanced life-saving skills for midwives working in developing countries.) 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% of the babies in a vertex position. Four percent were born persistent posterior and there were two face presentations. Occasionally we would be surprised by breech or twin births, but for the most part we referred those women to the hospital before labor. We also referred out, when at all possible, pregnancies we knew to be premature or post mature, or complicated by hypertension. The majority of our babies (90%) were between 2501 grams (5 pounds 9 ounces) and 4000 grams (8 pounds 13 ounces.) Ten percent were considered low birth weight at 2500 grams or under (5 1/2 pounds.) Our smallest baby was 892 grams (just under 2 pounds) and our largest was 4930 grams (10 pounds, 14 ounces) Practically all (99.8%) of our babies were breastfed at birth. At their parent’s request, 97% 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. Twenty percent of the babies required some help getting started breathing, with the majority (17%) only needing stimulating and blow-by oxygen, while 3% required PPV or CPR. Two percent of the newborns were transferred for care in a hospital at some time following birth.
Among common maternal complications there were hemorrhages, shoulder dystocia, and placenta problems. Although many texts now define hemorrhage as blood loss over 1000 cc, because our women are malnourished and often anemic, we use the more conservative definition of 500cc, and by that definition 17% of the mothers suffered a hemorrhage; however only 2% of the cases had blood loss greater than 1000cc. IV fluids were given in 15% of the cases, oxytocin in 33%, and methergine in another 9%. Because of the high number of cases where the placenta partially separated, the placenta was assisted to deliver with cord traction in half of all cases (54%). Maternal catherization was required 2% of the time, and manual removal of the placenta was required in 0.2% of all deliveries. Shoulder dystocia happened in 3% of the cases.
Neonatal mortality was 0.5%, but it might have been higher, due to the fact that not all parents returned with their babies for follow-up exams through six weeks. The deaths did not occur while in our care, with the exception of stillbirths. There were many complicating factors surrounding neonatal deaths because of the poverty of the parents and the lack of access to medical care for many. When a death did occur, autopsies were not done, so it was hard to ascertain the true cause of death. Infection, birth defects, and prematurity were the most commonly named causes.
Maternal mortality, defined as a death occurring within 42 days of birth, happened 4 times that we were aware of, for a statistic of 0.05% of births. In all cases the mother had checked out of our birth center and gone home, and only later did we find out that she had died. In one case, a woman died of tuberculosis, a common ailment in the Philippines that was no doubt made worse by her pregnancy. Another women checked out healthy but went to a local “healer” and received a rubdown with a gasoline and kerosene mixture, only to die days later of full body burns. In two more cases we heard that a postpartum patients had died days or weeks later, one from infection and one of unknown etiology. Again, this number may actually be higher than reported here, as not all women returned for follow up care.
Families were not charged of the midwifery services, or for the facility. Families that could afford it were asked for a donation to cover any medications or IV fluid used during labor, birth or postpartum. The birth centers practiced according to the guidelines of “Mother Friendly/Baby Friendly,” and did much to provide love, comfort, and support to poor women and their families during pregnancy, labor and birth.
Few types of maternal/child health services are as appreciated by the Filipino people we know as our freestanding charity birth centers. Here they are welcomed and loved, no matter how poor or downcast they happen to be. 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, while not sacrificing the comfort, kindness and personal care that they crave. Having student midwives always present is seen as a plus by the women, since there are always several pairs of hands and loving hearts to help them navigate the difficult waters of birth.
In this place where outcasts often come, and the weary sing their song, here we stand, here we pray…the midwives of Mercy In Action.