Title: The Development of Basic Emergency Obstetric and Newborn Care (BEmONC) and
Maternal Health in the Philippines: A Historical Literature Review
Authors: Gene A. Nisperos, MD, Mary Christine R. Castro, MD, Ana Pholyn A. Balahadia-
Mortel, MD, Cherylle G. Gavino, MD, MPM-HSD, and Maria Stephanie Fay S. Cagayan,
MD, PhD
Date Published: August 22, 2024
INTRODUCTION
Maternal Mortality Ratio (MMR) is a major indicator of a country's general health
care status. Attention has been given to maternal health since the 1980s. In
1990,2global MMR was at 385 deaths per 100,000 live births. A gross disparity was
notable between developed regions (23 deaths per 100,000 live births) and developing
and underdeveloped regions (430 deaths per 100,000 live births). The South-eastern Asian
region recorded 320 deaths per 100,000 live births.
Maternal health remains a challenge in the Philippines despite various interventions. This
paper explains how major policies and programs came about in the country and gives a
glimpse of their effect on MMR. It provides national historical context to guide
policymakers, educators, and healthcare providers in improving maternal health.MMR in
the Philippines varied widely based on different sources. The National
Demographic and Health Survey (NDHS) reported 213 deaths per 100,000 live births in
1986 and 209 in 1993, while the United Nations (UN) and Philippine Statistics
Authority (PSA) estimated MMR at 152 and 80.13, respectively, in 1990 (Figure 1).A 75%
reduction in MMR by 2015 was targeted by the Millennium Development Goal 5 (MDG
5).3 Different partnerships, approaches, strategies, programs, activities, and policies surfaced
across the globe to improve maternal care (Figure 2). The Philippines committed to
reduce MMR from 209 (1993 NDHS) to 52 deaths per 100,000 live births
Interventions Post-MDG
Countries shared learning experiences as they carried out their respective national
programs. Those with high MMRs were technically assisted by the World Health
Organization (WHO). Global agencies and funders supported the Philippines in
achieving its MDG commitments. The Women's Health and Safe Motherhood Project9
(WHSMP) was implemented in selected regions of the country from May 1995 to June
2002. It aimed to improve the health status of women, parti-cularly those of reproductive
age. Interventions were made in the areas of service delivery, institutional
development, community partnerships, policy, and operations research.From 2006 to 2012,
the Women's Health and Safe Motherhood Project 2 (WHSMP2) was launched and rolled
out in other regions based on recognizing that "good maternal health can also strengthen the
entire health system."10As the national government gave more attention to maternal
health, improvements in health financing, resources, service delivery, and policies followed.
In 2003, the Philippine Health Insurance Corporation (PhilHealth) started to offer
"Maternity Care Packages for Normal Spontaneous Delivery" in hospital and non-hospital
facilities.11,12In June 2005, the Department of Health (DOH) adopted the
FOURmula ONE for Health in its effort to take bolder steps in reforming the health
system towards the achievement of health goals. These reforms focused on 1) healthcare
financing, 2) health regulation, 3) health service delivery, and 4) good
governance.13,14By 2006, DOH also introduced the Health Facilities Enhancement
Program (HFEP), which supported the building of smaller health facilities such as
barangay health stations, birthing, and lying-in clinics, and infirmaries.
MATERIALS AND METHODS
A literature search was done in Medline, Scopus, HERDIN, and Google Scholar
from February to March 2021 using the keywords "BEmONC", "EmONC",
"BEmOC", "EmOC", "emergency obstetric care", "maternal health", "maternal mortality",
"MMR" and "Philippines" for a scoping search on the topic. Snowballing of cited
references was done, including grey literature. Policies, publications, reports, and
other issuances related to maternal health downloaded from the DOH website and
national legislation were reviewed. Annual reports and statistics were retrieved from online
databases, including the NDHS, Field Health Services Information System (FHSIS), PSA
Vital Statistics, Family Planning Survey (FPS), Family Health Survey (FHS), National
Nutrition Survey (NNS), UN, and Responsible Parenthood and Reproductive Health
(RPRH) reports. Additional data were also requested from the DOH on BEmONC updates
and status via email correspondence.
A historical literature review was carried out. Extracted data did not undergo statistical
analysis in this study. Although BEmONC includes obstetric and newborn care
interventions, this study focuses only on maternal health and mortality. This article
reviews BEmONC as an intervention and underscores the strengths and challenges in
its development and actual practice.
RESULTS
Shift to Emergency Obstetric Care Approach
As different interventions yielded varying results and led to new insights, conclusions,
and recommendations, paradigms likewise shifted and changed over time.Two basic
strategies that underpinned efforts to address high maternal mortality from the 1980s to
2000s were the training of traditional birth attendants (TBAs) and applying the risk
approach through ante-natal clinics.16 However, these strategies barely lowered MMR. In
2006, MMR in the Philippines remained high at 162 (FPS) and 104.15 (PSA) deaths per
100,000 live births (Figure 3).In 2009,13 the DOH attributed the high maternal mortality
mainly to the predominance of home births (61%) and the relatively high proportion (37%)
of births assisted by TBAs or "hilots". Based on the 2003 NDHS, while 88% of
women saw a health professional for ante-natal care, a significant number eventually
gave birth at home. This revealed that even though women were aware of the
importance of skilled birth attendants (SBAs), many were either unwilling to seek the
same level of care or were unable to access such care. In their paper, Lavado and
Lagrada17observed that regions with high percentages of births with-out skilled attendants
tend to have high MMR.Campbell et al.18 concluded in their study that "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." They emphasized the need for back up by "access to referral-level
facilities."Consequently, there was a major paradigm shift in maternal care from the
risk approach to the Emergency Obstetric Care (EmOC) approach. The EmOC
approach considered all pregnant women at risk of complications at childbirth. Thus,
two kinds of facilities for improved maternal health were established: Basic Emergency
Obstetric Care (BEmOC) and Comprehensive Emergency Obstetric Care (CEmOC)
facilities.
The Development of BEmONCs
With the advent of the EmOC approach, emphasis was placed on the importance of facility-
based deliveries (FBDs) assisted by SBAs provided within a referral network
system.Implementation of Basic Emergency Obstetric and Newborn Care
(BEmONC) has a promising potential to curb maternal mortality. In Ethiopia,19 a
dose-response relationship was noted between BEmONC implementa-tion strength,
FBDs and met needs at the primary health care level. They concluded that the
BEmONC Initiative effectively improved institutional deliveries and may have also
improved the met need for services.Initiatives in 2007 focused on upgrading BEmOCs and
CEmOCs. A training center was established in each of the main islands of Luzon,
Visayas, and Mindanao to ensure the improved quality of EmOC services.14The DOH
Administrative Order (AO) 2008-0029 "Implementing Health Reforms for Rapid
Reduction of Maternal and Neonatal Mortality" officially gave birth to the integrated
Maternal, Newborn and Child Health and Nutrition (MNCHN) Strategy.20 This approach
highlighted the importance of having committed skilled health professionals in
appropriate health facilities and a well-coordinated referral system. It also recognized the
province- or city-wide health system as the basic unit for planning, organizing, and
implementation.13The MNCHN strategy added newborn care services to EmOC facilities.
Thus, BEmOCs and CEmOCs became BEmONCs and CEmONCs. These facilities were
expected to provide specific signal obstetric functions and neonatal emergency
interventions.14 The MNCHN strategy was founded on the three pillars of reducing
maternal mortality:
1. Emergency obstetric care
2. Skilled birth attendants
3. Family planning
The MNCHN Service Delivery Network (SDN) had three levels of care:
(1) Community-level service providers;
(2) (2) BEmONC-capable networks of facilities and providers; and
(3) (3) CEmONC-capable facilities or networks. These three levels of care covered the
entire range of MNCHN services and functions. Over the years, the DOH strived to
address the gaps in MNCHN service delivery and utilization:
Health Infrastructure
Under DOH AO 2008-0029, local government units (LGUs) were tasked to invest in
the development of faci-lities.23 This pushed LGUs to increase the local budget for
facilities or actively source funds from grants and private-public partnerships.Improved
access to quality hospitals and health care facilities was one of the three major thrusts
of Universal Health Care, the Aquino Health Agenda24 from 2010 to 2016. Through
the HFEP, government-owned facilities were upgraded. In 2010, BEmONCs and
CEmONCs in regions with the highest MMR and blood facilities for emergency
obstetric care were included in the priorities for HFEP funding.25The DOH
continuously gave technical support to barangay health stations, birthing centers,
rural health units (RHUs), and hospitals to increase their respective capacities and make
them eligible for accreditation as EmONC-capable facilities.The highest number of
BeMONC-capable facilities was achieved in 2016 (3102 facilities). However, the latest
data in 2020 showed a decrease in this number by more than 30% (1929 facilities)
Health Human Resource
The DOH launched various deployment programs to address the lack of health human
resources, including SBAs. By 2015, the DOH deployed 398 physicians under the
Doctor to the Barrios program, 13,500 nurses through the Nurses Deployment
Program, 2700 midwives, and 40,851 community health teams.26Continuous training was
given to health professionals to staff EmONC facilities. In 2020, 8705 health
professionals were BEmONC-trained. From 359 BEmONC teams trained in 2011, there
were 2429 teams by 2020. To date, there are 31 training centers nationwide for
BEmONC teams.In 2016, 1636 BEmONCs had trained teams. In the 2018 RPRH
Annual Report, 1758 public birthing centers had trained teams.20 In 2020, 1854
facilities, representing 96% of all BEmONCs in the country, had trained teams.
Health Financing
The National Health Insurance Act of 2013 provided that PhilHealth would cover
even unenrolled women about to give birth. Coverage and case rates for ante-natal
care, maternity care, normal spontaneous deliveries, other methods of deliveries, and
payments for cases referred to hospitals were covered by PhilHealth circulars.
Health Policy
SBAs and FBDs were promoted, while TBAs were prohibited from performing
deliveries at home. This resulted in several LGUs creating local legislation to sanction home
births, commonly tagged as the "No Home Birthing Policy." These controversial ordinances
with varying degrees of penalties were passed in Marikina City, Pasig City, Nueva
Ecija, Pampanga, Sorsogon, Palawan, Oriental Mindoro, Negros Occidental, Iloilo,
Capiz, Bohol, Samar, Leyte, Agusan del Sur, Davao, General Santos City, and Sultan
Kuldarat.
Health Service Delivery
The MNCHN strategy was also expanded by the DOH to create the Reproductive Health,
Maternal, Newborn, Child and Adolescent Health and Nutrition (RMNCAHN) strategy.20
Emphasis was placed on the importance of access to reproductive health services
for women of the reproductive ages.
DISCUSSION
Maternal Mortality Post-BEmONC ImplementationBy 2015, the Philippines failed to
achieve the MDG 5 target of decreasing MMR to 52 deaths per 100,000 live births.
Numbers varied across different sources: 73.63 (FHSIS), 98.64 (PSA), 114 (UN
Estimates), and 204 (NNS) (Figure 5). This implied the lack of precision and questionable
accuracy of data collection. Nonetheless, all available sources were way above the target.
The rate of decline in maternal deaths also notably slowed in the Philippines
compared to other Southeast Asian countries.31Based on FHSIS data and the National
Objectives for Health1 (NOH) 2011–2016 Performance Indicators and Scorecards, there
was no significant improvement in access to family planning services, prenatal
consults, and post-partum visits despite the presence of BEmONCs. There was, however, a
percentage increase in live births by SBAs (74% to 86.13%) and more FBDs20
(38.14% to 85.96%) between 2008 and 2015.FBDs and SBAs were promoted as major
strategies to reduce maternal deaths. However, despite increases in FBDs and SBAs, there
was no direct progress observed in terms of MMR.15Failure to achieve global MDG
targets led to creating the Sustainable Development Goals (SDGs) to "finish what
was started."2 Under the Sustainable Development Goal32 3 (SDG 3), MMR should be
less than 70 deaths per 100,000 live births by 2030 globally. However, the latest data showed
that the Philippines was still way off from achieving this new target
BEmONC Functionality and Challenges to Performing Signal Functions
BEmONC facilities should be capable of performing the following signal obstetric
functions:
1. Parenteral administration of initial dose of antibiotics
2. Parenteral administration of oxytocin in the third stage of labor
3. Parenteral administration of loading dose of anticon-vulsants
4. Manual removal of retained placenta
5. Removal of retained products of conception
6. Performance of assisted deliveries
7. Neonatal resuscitation
However, a study commissioned by the United Nations Population Fund (UNFPA) in 201433
reported that only four percent of BEmONCs (21 were hospitals) could provide all the
expected signal functions. The study discussed several issues regarding the reasons for
the failure to perform signal functions in BEmONC facilities:
:• BEmONC facilities referred emergency and compli-cated cases directly to CEmONC
facilities or hospitals.
• Most of the signal functions were regarded as specialized functions that should be
performed with various special requisites and in a hospital setting only
.• PhilHealth rules reinforced the practice of BEmONC facilities attending to normal
spontaneous delivery cases only.
• Some local policies hindered contractual and deployed health personnel from being
BEmONC-trained.
• BEmONC training provided limited opportunities for performing certain
procedures, and follow-up and monitoring after training were minimally done.
• Training programs gave inconsistent instructions as to the functions of BEmONCs.
• Purchasing supplies and equipment depended on the availability of LGU funds and
local priorities.
Midwives remained hesitant to administer life-saving drugs due to legal liability. Patients
had to be referred to other facilities because only physicians were allowed to manually
remove the placenta and retained placental fragments.34The Implementing Rules and
Regulations of Republic Act 739235 only mentioned dispensing oxytocics and giving intra-
venous fluids as part of the midwives' professional practice.Deployment of health human
resource did not translate to having BEmONC-trained personnel in facilities. Some local
policies excluded temporary staff from receiving training. The retention of deployed
health professionals after their contracts should be considered.In some localities, the
reluctance of private clinics and practitioners to refer high-risk patients or complicated
cases to avoid losing their PhilHealth reimbursements has led to maternal deaths.36On
the other hand, PhilHealth policies required facilities to refer high-risk mothers to higher
facilities for patients to avail of the Maternity Care Package. This was anathema to the
expectation that BEmONCs should be able to perform all signal functions, which
included administering parenteral life-saving drugs, performing manual evacuation of
the placenta, removing retained products of conception, and doing assisted vaginal
delivery.Other contributory factors were the inadequacy of family planning
services, the lack of quality services during prenatal visits, the low importance given to
post-natal check-ups, and the reluctance of pregnant women to visit health facilities
due to opportunity costs such as foregone income and prolonged waiting time in the
clinic.36Although 96% of BEmONC facilities had trained teams and 85% passed the
licensing and accreditation requirements in 2020, BEmONC functionality generally
remained inadequate to address existing challenges in maternal health care, much less
decrease MMR. It is important to investigate why there are fewer BEmONC facilities in
2020 (1929) compared to 2016.
REFERENCES
1. Department of Health (DOH). National Objectives for Health, Philippines 2011-2016.
Manila, Philippines: DOH; 2012.
2. Trends in Maternal Mortality: 1990 to 2015: Estimates by WHO, UNICEF; World
Bank Group and the United Nations Population Division. Geneva, Switzerland: WHO;
2015.
3. United Nations Millennium Declaration. General Assembly Resolution 55/2.
New York City, USA: UN; 2000.4. Department of Health (DOH). Adoption of the Manual of
Operations on Maternal, Newborn, and Child Health and Nutrition (MNCHN) in the
Implementation of Programs, Projects and other Initiatives for Women and Children.
Department Memorandum No. 2009-0110. Manila, Philippines: DOH; 2009.5. The
Partnership for Maternal, Newborn, and Child Health, New Global Consensus on
Maternal, Newborn and Child Health to save 10 million lives [Internet]. 2009 [cited
2021 March]. Available from:
https://www.who.int/pmnch/media/press/2009/20090922_worldleadersconsensus/en/.6.
World Health Organization (WHO). Reducing Maternal Mortality. A joint statement by
WHO/UNFPA/UNICEF/World Bank. Geneva, Switzerland: WHO; 1999.
SUMMARY
SUMMARY
