Policy, purpose, and governing approach
- The Order aims to strengthen the capacity of midwives to adequately and appropriately respond to pregnancy-related complications.
- The Order requires reduction of maternal and newborn morbidity and mortalities through administration of life-saving drugs and medicines.
- The Order promotes rights-based service delivery and gender- and culture-sensitive service delivery.
- The Order adopts a three-pronged approach including:
- deliveries by skilled health personnel using a continuum of care approach;
- easy access to emergency obstetric and newborn care; and
- universal access to family planning and reproductive health services.
- The Order encourages facility-based deliveries and requires system-wide approaches.
Defined terms used in the Order
- BEmONC means Basic Emergency Obstetric and Neonatal Care.
- E/EmONC means Essential and Emergency Obstetric and Neonatal Care.
- ENC protocol means Essential Newborn Care protocol.
- Midwife means a person who:
- was regularly admitted to a midwifery educational program duly recognized in the country where it is located;
- completed the prescribed midwifery course of studies and acquired the requisite qualifications; and
- is registered and licensed to practice midwifery (WHO, ICM, FIGO).
- Life-Saving Drugs means drugs and medicines used to prevent and manage pregnancy-related complications, including Magnesium Sulphate, Oxytocin, Steroid, and oral antibiotics.
- Emergency conditions mean conditions that put the mother and the newborn at risk of complications or dying if not timely prevented or managed, including:
- Pre-eclampsia (after the 20th week of gestation, characterized by hypertension and proteinuria);
- Eclampsia (pregnancy or newly delivered woman, characterized by convulsions followed by coma; convulsions may occur antepartum, intrapartum or early postpartum);
- Post-partum Hemorrhage (blood loss greater than 500ml from the genital tract after delivery);
- Premature Labor (active contraction of the uterus before the 37th completed week of pregnancy);
- Infections.
Who must comply and where it applies
- The Order applies to all registered/licensed midwives who:
- provide skilled midwifery services, and
- intend to obtain Maternity Care Package (MCP) and Newborn Care Package (NCP) accreditations from PhilHealth.
- The Order also applies to the whole hierarchy of DOH and its attached agencies, as well as LGUs, and other development partners implementing the MNCHN strategy.
- The Order operationalizes the midwives’ role within emergency conditions when no physician is available.
Authority for midwives to give life-saving drugs
- The Order requires that midwives’ authority under the Order operates in addition to existing functions defined in Section 23 of the Midwifery Act of 1992.
- The Order allows midwives to administer life-saving drugs including:
- magnesium sulphate,
- oxytocin,
- steroids, and
- oral antibiotics.
- The authority is conditioned on midwives being appropriately trained and certified proficient to provide necessary care and services to prevent maternal and newborn deaths.
- The Order limits the intended use of these interventions to emergency conditions when no physician is available.
- The Order requires life-saving drug selection to follow the clinical practice protocol.
Training, certification, and supervision requirements
- Midwives who intend to obtain accreditation as E/EmONC providers must complete in-service training that is two-part:
- formal/didactic training; and
- practicum.
- Training must use approved modules and other instructional materials that upgrade knowledge and skills on E/EmONC.
- After the formal part, midwives must pass a post-training evaluation that includes:
- a written examination;
- practicum at the hospital training facilities; and
- application of skills to their areas of work.
- A midwife must pass the post-training evaluation after the formal part before being allowed to undergo practicum.
- A certificate of proficiency must be issued upon satisfactory completion of practicum within six months.
Clinical standards for each life-saving drug
- Magnesium sulphate (MgSO4) must be used for the prevention and management of eclampsia.
- Oxytocin must be administered for:
- active management of third stage of labor (AMTSL); and
- initial management of post-partum hemorrhage.
- Steroids must be administered for cases of preterm labor.
- Antibiotics must be administered for cases of infections.
Supervision, legal assistance, and governance roles
- Midwives must be supervised by the municipal, district, city or provincial health officer or senior midwife supervisors.
- Supervision must include technical guidance from POGS for maternal care.
- Supervision must include technical guidance from PSNbM and/or PPS for newborn/neonatal care wherever possible.
- Midwives must be provided legal assistance if needed in relation to their performance as E/EmONC providers, including in administering life-saving drugs.
- POGS must:
- conduct midwife training in appropriate training institutions nationwide;
- issue proficiency certification to midwives it directly trained practicing in covered areas;
- conduct monitoring, coaching, or field visits to assist midwives in their field of assignment; and
- conduct or participate in regular maternal death reviews under the Maternal Death Review (MDR) protocol.
- POGS must conduct perinatal death review in collaboration with PSNbM, PPS, and/or PAPI under the Perinatal Death Review (PDR) protocol.
- PSNbM/PPS and/or PAPI must coordinate with POGS for:
- training of midwives in newborn care areas;
- monitoring, coaching, or field visits on newborn care; and
- regular maternal and newborn death reviews under MDR and PDR protocols.
- Midwives Associations must:
- update their rosters to ensure appropriately trained practicing, licensed midwives;
- ensure proper representation in maternal and perinatal mortality and morbidity reviews; and
- conduct monitoring and internal audit to ensure adherence to standards, norms, and quality assurance protocols.
- LGUs must:
- ensure LGU midwives have necessary and updated licenses and provide financial support for training/capacity enhancement on E/EmONC;
- ensure LGU facilities have adequate supplies, equipment, drugs, and medicines at all times and develop infrastructure for quality E/EmONC delivery;
- ensure LGU-managed hospital facilities are accessible for training and maternal/perinatal death reviews;
- activate, sustain, and expand local health board membership to include representatives of local chapters of POGS, midwives associations, and PPS/PSNbM and/or PAPI;
- ensure enrollment of indigent families and PhilHealth MCP accreditation of all birthing facilities in their jurisdiction; and
- set up a functional referral system and service delivery network using both public and private facilities and providers for continuum of care.
- DOH units must implement specific support functions:
- National Center for Disease Prevention and Control: provide technical assistance to CHDs and LGUs and ensure compliance to standards and protocols governing administration of life-saving drugs and medicines; coordinate with Health Human Resource Development Bureau (HHRDB) in identifying training hospital facilities.
- HHRDB: provide technical assistance and human resource support in training and education of midwives.
- Bureau of International Health Cooperation: ensure proper coordination of development partner technical assistance for training, education, and facility improvement.
- DOH-Centers for Health Development (CHD): provide technical assistance, monitoring, and evaluation of local-level implementation.
- DOH-retained hospitals: serve as training facilities and ensure access to clinical materials for midwives undergoing training.
- Development partners must support implementation through technical and financial assistance for training, research, education, and facility enhancement needed to further the issuance.
Monitoring, reporting, and review
- The Order requires quality assurance and clinical audit at least once a month by DOH-CHDs Local Health Support Division and its retained hospitals.
- Progress reports must be submitted to the Office of the Secretary.
- The Order requires an annual implementation review with stakeholders.
Repeal, modification, and remaining effect
- Provisions of previous orders and other related issuances that are inconsistent or contrary with the Order are revised, modified, repealed, or rescinded accordingly.
- All provisions of existing issuances that are not affected by the Order remain valid and in effect.