Making the continuum of care possible

The twin challenges to Puerto Princesas maternal health

The provision of a comprehensive maternal health program requires a functioning health system and effective delivery of an integrated maternal health package.
WORLD HEALTH ORGANIZATION

THIS POLICY BRIEF IS INTENDED TO GIVE GUIDANCE TO LOCAL CHIEF executives and other local health policy makers on the critical issues of securing the continuity of maternal health care in communities, specifically in Puerto Princesa City, Palawan. It identifies two essential factors that affect program interventions at multitiered levels: a functioning health system and the socioeconomic push and pull causes disrupting the continuum of maternal care.
ISSUE Puerto Princesa City is no different to cities or provinces having high maternal mortality with under resourced finances. Although there may be broad agreements among health experts, legislators and local chief executives, there is far less consensus on the main reasons why. Puerto Princesa City has 66 barangays and it entrenches several geographical, isolated and displaced areas within the periphery. In 2009, Puerto Princesas maternal mortality rate is 94.50 and as of September of 2011 the city has no reported maternal deaths. Despite this conscious effort, many pregnant mothers in the community have not visited their rural health units. Some factors that may contribute to this predicament is the proximity of pregnant mothers to health care facilities, lack of quality maternal health care services, lack of human resources for health and the relatively low seeking-behavior for health services. Moreover, accounts from pregnant mothers prefer to give birth at homes than in health facilities due to possible out-of-pocket expenditure. Currently, government efforts to ease the burden of medical costs has not been realized due to inadequacy of services that can be provided by the national health insurance program. The situation in Puerto Princesa City, just like in any highly urbanized city, is that domestic funding is not encouraging. Because on the severe constraints in government revenues, coupled with the geographical scale of the locale, little improvement in the amount of funds from these sources for maternal care programs can be anticipated.

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MIMAROPA POLICY BRIEF SERIES

Making the continuum of care possible

EVIDENCE Poor political choices aside, the lack of focus on maternal mortality can also be partly explained by the complexity of tackling the problem. Global evidence claim that success requires countries to build a health system that is strong, with emergency obstetric care, blood, ability to do caesarean section close to people. Then again, building a health system on a miniscule budget and limited aid is a huge challenge for Puerto Princesa City. On a hind sight, from the FHSIS 2010, prenatal visits show that only Barangays San Jose, Santa Monica, San Manuel, San Pedro and Bancaobancao had more than 123 mothers visiting the City Health Unit for at least four (4) prenatal check-ups (please see Figure 1.0). These barangays also has the greatest concentration of Pantawid Pamilyang Pilipino Program (4Ps) of the Department of Social Welfare and Development, aside from the fact that these areas are constantly visited by community health workers via medical missions. This implies that the concentration of pregnant mothers are relatively thick in poblacions, and roughly 7.5% of the whole Puerto Princesa Citys pregnant mothers are regularly checked which presents several policy and program implications. The whole continuum of maternal care starts from family planning, pregnancy care including prenatal check-ups, vitamin A and iron supplementation, pregnancy care, childbirth care, and postpartum care. Further investigating on maternal care indicators for the identified barangays, on Figure 2.0 shows the greater disparity of pregnant and postpartum women given iron (which are the last stages of prenatal and postpartum care). Barangays San Jose, San Manuel and San Pedro has roughly indicated slower follow-ups on postpartum care. This implies that fewer mothers are given assessment of maternal well-being, prevention and detection of future complications, anaemia prevention, treatment of minor problems such as puerperal depression, pre-referral treatment and most importantly, recording and reporting of information from the mothers. The Postpartum care component of the continuum is essential for early identification and appropriate management of complications, family planning and birth spacing, support for breast feeding, possible care and counselling for HIV positive mother. More than that, postpartum care provides timely management of maternal sepsis that will reduce the risk of maternal mortality due to sepsis by 90%. Low access to information may be contributory to this low
FIGURE 1: Map of Puerto Princesa City indicating areas with Pregnant women with 4 or more prenatal visits

The twin challenges to Puerto Princesas maternal health

accomplishment, further evaluating the functionality of service delivery that supposedly should ensure that these program services are available, accessible and acceptable to all women in the service area despite the financial capacity of pregnant mothers to visit rural health units. With this, the twin challenges of Puerto Princesa City to have a functional service delivery system and securing the continuity of maternal care requires critical social policy implications.

FIGURE 2: Pregnant Women given Iron versus Postpartum Women given Iron, CY 2010

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Making the continuum of care possible

BUNTIS BABY BANK: THE CAJIDIOCAN, ROMBLON EXPERIENCE
* excerpt from the article of Dr. Heidee Exconde, MHO in ISLA MIMAROPA

WHAT WORKS

The twin challenges to Puerto Princesas maternal health

POLICY ACTIONS AND RECOMMENDATIONS The Buntis Baby Bank (BBB) project, originally conceptualized by Dr. Chua of Milagros, Masbate, and replicated by Dr. Heidee Exconde of Cajidiocan Romblon has proven promising results in the development of continuum of maternal care. In the early indications, the BBB project shown 5-12 increase in percentage in all maternal care indicators, even highlighting community solidarity from local chief executives, barangay captains, relatives and pregnant mothers themselves. Moreover, the project also provided the principle of a social health insurance which is to place collected financial contributions in a fund from which health-care costs (for the contributing members) are paid out. Establishing pathways for creating pooling mechanisms is a prerequisite in achieving financial risk protection, in this case, in maternal care. Policy makers should note that many of the elements in abiding the continuum of maternal care can be implemented in resource-poor settings in the context of resource-pooling schemes. Once a resource-pooling scheme is set up, it needs to be managed efficiently. Maternal care services may be provided by the government or the barangay may purchase them from private sector or a combination of different purchasing modalities used by existing health care systems. POLICY RECOMMENDATION

The Municipality of Cajidiocan, Romblon is one of the communities that have struggled with its maternal and child health outcomes. Poor health-seeking behavior has led to some mothers with no or insufficient prenatal care be deprived of the proper care and counseling as well as the vitamin supplementation needed. The first two quarters of 2009 revealed that only 18% of pregnant women sought and has been given quality prenatal care with at least 4 prenatal check-ups. These challenges led to two maternal mortalities last 2008 and early 2009. The problem looms bigger as the poor financial status of majority of the mothers contributed to poor referrals to health units and hospitals since the lack of funds could not pay for the health services especially in the hospitals. These distressing challenges led to the birth of the Buntis Baby Bank Project that functions by assigning a baby bank made up of bamboo to all pregnant mothers seeking prenatal care at the RHU. The baby bank is placed in a highly visible area in the RHU, allowing the mothers and other people to drop any amount anytime, resulting to accumulated savings until their delivery date. The savings accumulated will be used when the mother reaches her delivery date with the extra savings to be used postpartum, for the care of the baby, or even to assist the mother avail of the family planning method of her choice (i.e. pills, ligation). The project has resulted in better maternal health outcomes as it has encouraged more prenatal visits especially from mothers in their 1st trimesters as seen by the 18% to 27.5% increase in the pregnant women receiving at least 4 prenatal care. No maternal mortality again occurred since project implementation. Facility-based deliveries have continued to increase from 83% to 92%. The project has presented an initiative towards producing equitable health care financing by means of the banking system that is being made available to the mothers. This health financing scheme has assisted the mothers to prepare financially for a safe delivery (average withdrawal of Php 500-600 saved in at least 5 months). Moreover, LGU participation has been brought about through the inclusion of the project in the Municipal Ordinance 09-09 on Facility-Based Deliveries of the municipality. As stated in Section 2.3, All punong barangays are also enjoined to establish Buntis Baby Banks in their Barangay Health Stations to help mothers to save for delivery. The LGU officials have also given their share in adding up to the savings of the pregnant mothers.

Enjoining punong barangays in establishing Barangay Buntis Baby Banks in Barangay Health Stations to help mothers to save for delivery and ensure the continuum of maternal care after giving birth as a stop-gap measure As medical technology has advanced at a rapid pace, the health care delivery system has floundered in its ability to provide consistently high quality to care. This implies that increased know-how and increased resources will not, in themselves, translate into the high quality of care which populations and individuals rightly expect. How one organizes the delivery of care has become as important. Functionally, each city health unit links families and communities to ensure support and care for mother and baby. In order to do so, skilled professionals should be available to provide all women with quality postpartum care, coupled with essential medicines and medical devices, functional referral systems, recording system and regular maternal and perinatal death reviews at facility level to improve quality of care. The establishment of halfway houses can also contribute to mitigate geographical constraints hindering access to quality care.

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MIMAROPA POLICY BRIEF SERIES

Making the continuum of care possible

Improved quality outcomes are not however, delivered by health providers alone. Communities and service users are the co-producers of health. They have critical roles and responsibilities in identifying their own needs and preferences, and in managing their own health with appropriate support from health service providers. In support to the functionality of a health system, communities shall be empowered to address postpartum care interventions at different levels. To wit, interventions at home or community levels, can include information and counselling on self care at home, nutrition, safer sex, exclusive breastfeeding, family planning, healthy lifestyle and support for rest and less work load. Likewise, quality improvement is about change and for this reason, an important early step in decision-making process is the involvement of key stakeholders that would remain involved in all stages of the process. POLICY RECOMMENDATION Community health teams will be assigned to each family, do house-tohouse visits, reach all families with priority CCT/NHTS families and provide critical health services when needed, link families to health service providers and deliver key messages critical to maternal care. Driven by available information, as well as stakeholder participation, an agreed quality improvement strategy could be produced in such a short period. In abiding the continuum of maternal care, information is fundamental because any quality improvement is dependent on the cpacity to measure change in processes and outcomes, and on stakeholders having access to information that changes what they do. POLICY RECOMMENDATION

The twin challenges to Puerto Princesas maternal health

Adopting the organization of community health teams to link families to health care prorgrams and increase the presence of health and social sector in communities

Developing locally agreed standards and local protocols for maternal care services and timely referral and management of complications at different tiers of interventions
References Electronic Field Health Service Information System, 2009-2010 MIMAROPA POLICY BRIEF SERIES

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