Traditional Birth Attendant (Hilot) Integration & Referral - Cheat Sheet
Your last-minute revision companion for TBA policy, the midwife's supervisory role, and facility-based delivery advocacy. Focus on DOH policy, referral chains, and the TBA's redefined scope under RA 7392 context.
Who Is the TBA / Hilot?
Important facts
- TBAs command deep community trust and speak local dialect — they are embedded in barangay life.
- TBAs cannot reliably recognise or manage the leading causes of maternal death: haemorrhage, eclampsia, obstructed labour, sepsis.
- TBAs are NOT trained in emergency skills (oxytocics, manual removal of placenta, assisted delivery, resuscitation).
- The Philippines historically relied heavily on TBAs for home deliveries; maternal mortality was high.
- Global evidence shows every birth needs a Skilled Birth Attendant in a facility with emergency capability to reduce maternal death.
Key definitions
Traditional Birth Attendant (TBA) / Hilot / Komadrona / Mananabang
Example
An elderly woman in a remote barangay who has attended many home deliveries through observation and practice, not formal health-professional education.
A non-formally trained community member who assists childbirth using apprenticeship, custom, and experience; commands community trust but cannot recognise or manage obstetric complications.
Skilled Birth Attendant (SBA)
Example
A registered midwife working in an RHU or BHS with access to emergency referral protocols and BEmONC facilities.
A health professional (doctor, nurse, or registered midwife) with formal training who can manage normal labour, recognise complications, and provide or arrange emergency obstetric care.
BEmONC (Basic Emergency Obstetric and Newborn Care)
Example
A Rural Health Unit with trained midwife, oxytocin stock, magnesium sulphate, and referral protocol to the nearest CEmONC hospital.
First-level facilities (usually RHU/BHS level) equipped to provide signal functions: antibiotics, oxytocics, anticonvulsants, manual removal of placenta, assisted vaginal delivery, neonatal resuscitation.
CEmONC (Comprehensive Emergency Obstetric and Newborn Care)
Example
A district or provincial hospital with obstetric surgeon, operating theatre, blood bank, and NICU; receives complicated cases from RHU via referral chain.
Hospital-level facilities with surgical capacity (caesarean section, laparotomy) plus all BEmONC signal functions; receives referrals from lower-level facilities.
Why DOH Policy Changed: The Shift to Facility-Based Delivery
Important facts
- The Philippines had historically high MMR (Maternal Mortality Ratio); TBA-attended home deliveries accounted for a large share of preventable deaths.
- The leading direct causes of maternal death — PPH, eclampsia, obstructed labour, sepsis, unsafe abortion complications — can appear suddenly in a labour that looked normal.
- These emergencies kill within HOURS without skilled intervention (oxytocics, anticonvulsants, blood transfusion, surgery); a TBA at home cannot provide these.
- AO 2008-0029 and MNCHN strategy pushed the system toward facility-based, skilled-attendant care linked by BEmONC/CEmONC referral networks.
- The policy does NOT endorse TBAs conducting deliveries; instead, it redefines TBAs as community mobilisers and referral partners.
- Some LGUs have enacted local ordinances restricting home births by TBAs, though this approach is debated for rights-and-access concerns.
- The professionally sound stance: advocate facility birth as the safe default, but address barriers (cost via PhilHealth, transport, respectful facilities) rather than coercion.
Key definitions
AO 2008-0029 (Administrative Order)
Example
The policy foundation cited in most TBA/facility-delivery MLE questions; establishes BEmONC/CEmONC networks and redefines TBA role.
DOH's flagship reform order titled 'Implementing Health Reforms for the Rapid Reduction of Maternal and Neonatal Mortality'; anchors the shift to facility-based, skilled-attendant delivery.
MNCHN (Maternal, Newborn, Child Health and Nutrition Strategy)
Example
Underpins messaging to communities: facility birth with a skilled attendant is the safe default; supports PhilHealth linkages and transport advocacy.
Broader DOH strategic framework that reinforces facility-based delivery, skilled attendance, and emergency referral as core to reducing preventable maternal and newborn death.
Facility-Based Delivery Policy
Example
A pregnant woman is counselled to deliver at the RHU with the midwife, not at home with the hilot, to ensure access to emergency care if labour turns complicated.
DOH directive that every delivery should occur in a facility (RHU, BHS, lying-in, hospital) attended by a skilled provider; TBAs are no longer to conduct home deliveries.
The TBA's Redefined Role Under DOH Policy
Important facts
- The trained TBA is a BRIDGE TO SKILLED CARE, not a birth attendant.
- Legitimate TBA functions: case-finding, motivating ANC and facility birth, referring, accompanying, and health promotion.
- TBAs are NOT to independently conduct deliveries, manage labour complications, or make clinical decisions.
- TBAs are NOT trained to give oxytocics, manage bleeding, administer magnesium sulphate, deliver the placenta manually, or resuscitate a baby.
- The TBA's community trust is an ASSET — if preserved through respectful collaboration, it drives case-finding and referral.
- The TBA is part of the barangay MCH team alongside BHWs, midwife, and RHU staff.
- Effective TBA integration requires TRAINING on danger signs, referral protocols, and the limits of her role.
Key definitions
Case-Finding
Example
A hilot notices her neighbour is pregnant, refers her to the barangay health worker, who registers her in the RHU's ANC program.
The TBA's responsibility to identify and report pregnant women in the community early so they can be registered and linked to prenatal care.
Motivation / Health Promotion
Example
The hilot tells a pregnant woman, 'The midwife at the RHU will make sure you and your baby are safe; we go there together when labour starts.'
The TBA counsels women to attend ANC, plan a facility birth, deliver with the midwife, and follow postnatal and newborn care protocols.
Referral and Accompaniment
Example
When labour begins, the hilot walks the woman to the RHU and stays as a labour companion; if a complication is detected, she helps transport to the hospital.
The TBA recognises when the woman needs skilled care, refers her to the midwife/facility, and may travel WITH her to ensure she reaches care and feels supported.
Birth / Labour Companion
Example
The hilot sits with the labouring woman, offers water, encourages position changes, and ensures her mother or husband can be present—respecting custom while the midwife manages clinical care.
The TBA provides non-clinical emotional support, respects cultural practices (e.g., position, presence of family), and communicates the woman's wishes to the skilled attendant.
The Registered Midwife's Supervisory & Collaborative Role
Important facts
- The midwife is the SKILLED ANCHOR for TBAs in her catchment area.
- The midwife TRAINS TBAs on danger signs, referral protocols, and what NOT to do at home.
- The midwife SUPERVISES TBA community activities and keeps collaboration, not confrontation, as the operating stance.
- Alienating a trusted hilot risks pushing families AWAY from skilled care; respectful partnership brings them INTO the system.
- The midwife RECEIVES referrals from TBAs and provides normal care herself, escalating beyond-scope cases to a physician/hospital.
- The midwife ADVOCATES facility-based delivery persuasively, respecting culture while moving practice toward safe, skilled, facility care.
- Effective integration requires that the midwife make the TBA feel VALUED and LISTENED TO, not dismissed or controlled.
Key definitions
Training and Orientation
Example
The RHU midwife conducts a quarterly session for local hilots: recognising eclampsia signs, when to call the midwife, how to accompany a woman in labour without interfering clinically.
The midwife formalises the TBA's understanding of her redefined scope, danger signs, referral pathways, and the requirement for facility-based delivery.
Supervision
Example
The midwife visits barangays monthly, meets with TBAs, asks what cases they encountered, and reinforces best practices for case-finding and referral.
The midwife maintains regular contact with TBAs in her catchment, reviews community births/referrals, provides feedback, and ensures alignment with facility-based policy.
Collaboration
Example
When a TBA brings a pregnant woman with hypertension to the RHU, the midwife thanks her publicly, explains the referral to the woman, and reports back to the TBA after management.
The midwife works WITH (not against) TBAs, respects their standing in the community, and turns their trust into a referral pipeline.
Two-Way Referral and Feedback
Example
TBA refers woman with suspected eclampsia to midwife; midwife stabilises, refers to hospital with a written referral note; hospital sends summary back to RHU midwife and TBA confirms receipt.
A documented, timely referral note travels with the patient; the receiving facility communicates back to the referring midwife/TBA about the outcome.
The Referral Chain: TBA → Midwife → Physician / BEmONC / CEmONC
Important facts
- The referral chain is FUNCTIONAL and EFFECTIVE when: (1) danger signs are recognised early, (2) transport is rapid, (3) the receiving facility is notified in advance, (4) feedback returns.
- Every level of the chain has a responsibility: TBA (identify and refer), midwife (screen, manage normal, refer complicated), physician (manage emergency).
- A BROKEN REFERRAL CHAIN — when a TBA sends a woman to the wrong place, or the midwife does not know where to send her, or transport fails — results in maternal death.
- The referral MUST BE DOCUMENTED, even if verbal. A written note or phone call with confirmation is essential for continuity and accountability.
- The midwife and TBA must know the LOCATION, CONTACT, and OPERATING HOURS of the referral facility (RHU physician, BEmONC BHS, CEmONC hospital).
- An emergency referral does NOT wait for a stable patient; it is initiated as soon as danger is recognised.
- Under the Anti-Hospital Deposit Law (RA 8344, as amended by RA 10932), a hospital cannot demand a deposit before providing emergency obstetric care — important for poor families.
Key definitions
Referral Chain / Referral Network
Example
A woman with a normal pregnancy identified by the hilot → referred to RHU midwife for ANC → planned facility delivery at RHU → if eclampsia detected, referred to district hospital CEmONC.
A structured, documented pathway for women to move from community (TBA) to primary care (midwife) to secondary/tertiary care (hospital) based on level of risk and need.
Timely Referral
Example
Midwife detects excessive vaginal bleeding in second stage → calls ahead to hospital, arranges transport, gives first-aid oxytocic, accompanies the woman.
The TBA or midwife recognises a danger sign or complication and immediately arranges transport and communication to the next level, without delay.
Documented Referral
Example
RHU midwife writes: 'Primigravida, BP 160/110, reflexes brisk, foetal heart 140/min — suspected eclampsia. Given loading magnesium sulphate, IV fluids. Urgent referral to CEmONC.'
A written referral note (or verbal message confirmed by repeat-back) travels with the woman to the receiving facility and includes clinical information, interventions given, and observations.
Two-Way Communication / Feedback
Example
Hospital sends SMS or written note to RHU: 'Woman delivered, baby healthy, managed eclampsia with magnesium and methyldopa, discharged day 3. Follow-up at RHU.'
After receiving a referral, the hospital facility communicates back to the RHU midwife (and TBA if involved) about the outcome, diagnosis, and management, closing the referral loop.
Diagrams to know
- Referral pathway flowchart: TBA identifies → TBA refers to midwife → midwife screens → normal labour (midwife-attended delivery) OR complication (referral to physician/hospital)
- Communication pattern: TBA → Midwife → Hospital → feedback loop back to Midwife & TBA
Facility-Based Delivery Advocacy: Making Safe Care the Easy Choice
Important facts
- Advocacy is NOT coercion — it is persuasion grounded in respect and problem-solving.
- The midwife's role is to make facility birth the EASY, TRUSTED, CULTURALLY ACCEPTABLE default.
- Cost is a major barrier for poor and rural women; LINKAGE TO PHILHEALTH removes this obstacle.
- Distance and lack of transport are major barriers; a COMMUNITY EMERGENCY TRANSPORT PLAN solves this problem at the barangay level.
- A birthing facility that is COLD, DISRESPECTFUL, or DISMISSIVE of culture drives women AWAY; facilities must be welcoming and dignified.
- When the hilot is brought INSIDE the system as a mobiliser and labour companion, communities move toward facility birth without feeling their traditions are erased.
- The message is: 'The midwife will deliver your baby safely WITH you, not instead of you. The hilot can stay and support you.'
Key definitions
PhilHealth Maternity Care Package
Example
A poor pregnant woman is registered in PhilHealth; the RHU midwife explains that her delivery and the baby's care are covered — no deposit needed.
DOH insurance scheme that covers ANC, delivery, and postnatal care for registered pregnant women; removes cost as a barrier to facility birth.
Community Emergency Transport Plan (Birth-and-Emergency Plan)
Example
Barangay captain designates a driver and vehicle; TBA/BHW knows the driver's mobile number and calls immediately if emergency referral is needed.
A barangay-level arrangement to ensure reliable transport (motorcycle, jeepney, or community vehicle) is available 24/7 if a pregnant woman needs rapid referral.
Culturally-Sensitive Facility Birth
Example
The RHU lying-in allows the woman's mother to attend labour, permits squatting or lateral positions, serves local food post-delivery — but maintains clean delivery practices and emergency protocols.
A birthing environment that respects local customs (e.g., presence of family, position choices, food preferences) while maintaining clinical safety standards.
Facility Respectfulness
Example
The midwife greets the woman by name, explains why she is checking blood pressure, drapes her respectfully, and asks permission before touch.
The midwife and staff treat labouring women with dignity, listen to their concerns, explain procedures, and respect modesty — building trust in institutional care.
Legal & Policy Framework
Important facts
- RA 7392 defines the midwife's scope: provide normal care and RECOGNISE and REFER complications—not to manage complications independently.
- AO 2008-0029 is the flagship DOH policy cited in almost all TBA/facility-delivery MLE questions.
- The Anti-Hospital Deposit Law protects emergency referrals; midwives should know this to reassure families and ensure transport is not delayed by money.
- Local ordinances restricting home birth must be implemented with ENABLEMENT (PhilHealth, transport, respectful facilities), not just RESTRICTION, to avoid driving births underground.
- The midwife's professional duty is to advocate facility-based birth while respecting women's autonomy and addressing real barriers to access.
Key definitions
RA 7392 (Midwifery Law)
Example
Under RA 7392, a midwife can conduct normal delivery and give immediate first aid (oxytocics, manual removal of placenta) but must refer eclampsia, severe bleeding, or obstructed labour to a physician.
Philippine law that defines a midwife as an independent primary provider of NORMAL maternal, newborn, family-planning, and community care who recognises and REFERS complications.
AO 2008-0029 (Administrative Order — Rapid Reduction of MMR/NMR)
Example
This order is the foundation for DOH messaging that TBAs should no longer deliver babies at home; it supports training TBAs as community mobilisers.
DOH policy anchoring facility-based, skilled-attendant delivery; establishes BEmONC/CEmONC networks and redefines TBA role as case-finding and referral partner, not birth conductor.
RA 8344 (Anti-Hospital Deposit Law), as amended by RA 10932
Example
A midwife transfers an eclamptic woman to a hospital; the hospital must provide emergency care immediately, even if the family has no money at that moment.
Law prohibiting hospitals from demanding a deposit before providing emergency obstetric care; ensures poor women can access emergency referral without upfront payment.
Local Ordinances on Home Birth
Example
A municipality may require all births to be attended by a skilled provider in a health facility; however, this approach must address barriers (transport, cost) or it may push births underground.
Some LGUs have enacted ordinances restricting or penalising home deliveries by TBAs; these reflect the facility-based-delivery policy but are debated on rights/access grounds.
Why Skilled Attendance Saves Lives: Clinical Reality
Important facts
- NORMAL LABOUR CAN TURN DANGEROUS WITHOUT WARNING — this is why even low-risk pregnancies need a skilled attendant in a BEmONC-capable facility.
- A TBA at home has NO MEDICATION (oxytocics, anticonvulsants, antibiotics), NO EQUIPMENT (IV access, BP cuff, foetal monitor), and NO BACKUP to manage a life-threatening emergency.
- A midwife at an RHU or BHS with oxytocics, magnesium sulphate, antibiotics, and IV access can manage most emergencies or stabilise and refer.
- The FIRST INTERVENTION often saves the life — a single dose of oxytocin for uncontrolled bleeding, magnesium sulphate for eclampsia seizure, antibiotics for sepsis.
- Referral to a CEmONC hospital (with operating theatre and blood bank) takes time; if a woman is delivered at home and complications arise, that time may not be available.
- This is the EVIDENCE BASE for the DOH facility-based-delivery policy: skilled attendance in a equipped facility saves maternal and newborn lives.
Key definitions
Leading Direct Causes of Maternal Death
Example
A woman delivering what looked like a normal labour suddenly bleeds heavily after the baby is born; without oxytocics and skilled care, she can die within 2 hours.
Postpartum haemorrhage, hypertensive disorders (pre-eclampsia/eclampsia), obstructed/prolonged labour, sepsis, and complications of unsafe abortion — all of which can appear suddenly and kill within hours.
The Margin for Rescue
Example
A woman develops eclampsia (seizures); without magnesium sulphate and monitoring, she may have cerebral haemorrhage or respiratory failure within 1–2 hours. A midwife in an RHU can give magnesium and refer for emergency care in time.
The window of time between recognition of a life-threatening complication and death is often MINUTES TO HOURS, not hours to days; skilled attendance in a BEmONC facility is the only reliable rescue.
Signal Functions (BEmONC capabilities)
Example
An RHU with a trained midwife can provide oxytocics for bleeding, mag sulphate for eclampsia, antibiotics for sepsis, manual removal of placenta, and assisted delivery — covering the most common obstetric emergencies.
Seven clinical skills a BEmONC facility must have: antibiotics, oxytocics, anticonvulsants (mag sulphate), manual removal of placenta, assisted vaginal delivery (vacuum/forceps), neonatal resuscitation, and blood transfusion.
Common MLE Scenarios & Pitfalls
Important facts
- MLE will test whether you PRESERVE the TBA relationship while advocating facility birth — not whether you can simply forbid home delivery.
- Questions about TBA role will focus on REDEFINED duties (case-finding, referral, accompaniment) NOT delivery or complication management.
- Questions about the midwife's responsibility will emphasise TRAINING, SUPERVISING, and COLLABORATING with TBAs — turning them into referral partners, not competing with them.
- Expect scenario questions where you must show: (1) respect for the TBA, (2) clear facility-birth messaging, (3) addressing barriers, (4) documenting and feeding back on referrals.
- The MLE will NOT ask 'Why are TBAs bad?' but rather 'How do you work WITH TBAs to move births safely to facilities?'
- High-yield MLE questions: DOH policy citations (AO 2008-0029, MNCHN), TBA scope under new policy, referral chain steps, and how the midwife supervises TBAs.
Key definitions
Scenario: A woman is 9 months pregnant. The hilot says, 'I will deliver your baby at home like I have for 30 years.' The midwife should...
Example
Correct response: 'Hilot, we value your care. Please help this mother get to the RHU when labour starts — you can stay and support her there, and the midwife will ensure safe delivery.' Wrong response: 'No, you cannot deliver at home; it is illegal and dangerous.'
NOT confrontationally order the woman to the facility, but respectfully counsel facility birth, explain benefits, address barriers (cost via PhilHealth, transport), and involve the TBA as a partner ('Hilot, please bring her to the RHU when labour starts').
Scenario: The TBA brings a labouring woman with severe vaginal bleeding to the RHU. The midwife should...
Example
Correct: 'Thank you for bringing her quickly! This heavy bleeding is serious. We are giving her medicine and she will go to the hospital now. I will call you tomorrow with news.' Wrong: dismissing the TBA or treating her like a nuisance.
THANK and PRAISE the TBA publicly for recognising danger and referring quickly; manage the emergency with oxytocics/IV/referral; and report back to the TBA about the outcome.
Scenario: An MLE question asks, 'What is the TBA's role in facility-based delivery?' The answer is NOT 'to deliver the baby,' but...
Example
Correct answer: case-finding, motivation, referral, accompaniment, health promotion. Wrong answer: to conduct the delivery or manage labour complications.
To identify pregnant women, motivate facility ANC and delivery, refer to the midwife, accompany the woman during transport and labour, and provide non-clinical emotional/cultural support.
Must remember
- The TBA (hilot/komadrona) is a NON-FORMALLY TRAINED community member — she commands trust but CANNOT manage obstetric complications.
- DOH Policy (AO 2008-0029, MNCHN) mandates FACILITY-BASED DELIVERY by a Skilled Birth Attendant; TBAs are NO LONGER to conduct home deliveries.
- The TBA's REDEFINED ROLE: case-finding, motivation for ANC and facility birth, REFERRAL to the midwife, accompaniment, and health promotion — NOT delivery or complication management.
- The REGISTERED MIDWIFE trains, supervises, collaborates with, and receives referrals from TBAs. She is the skilled anchor linking community to facility care.
- A FUNCTIONING REFERRAL CHAIN is: TBA identifies → refers to midwife → midwife screens and manages normal OR refers to physician/hospital. Referral is DOCUMENTED, TIMELY, and TWO-WAY.
- The leading causes of maternal death (PPH, eclampsia, obstructed labour, sepsis) CAN APPEAR SUDDENLY in a labour that looked normal and KILL WITHIN HOURS without skilled intervention.
- Every birth, even low-risk, needs a Skilled Birth Attendant in a BEmONC-capable facility because normal can turn dangerous without warning, and the margin for rescue is MINUTES TO HOURS.
- BEmONC signal functions: antibiotics, oxytocics, anticonvulsants, manual placental removal, assisted vaginal delivery, neonatal resuscitation. These first-level interventions save most emergencies.
- Under RA 8344 (Anti-Hospital Deposit Law, amended RA 10932), a hospital CANNOT demand a deposit before providing emergency obstetric care — ensures poor families can access emergency referral.
- The professionally sound stance: ADVOCATE facility birth while ADDRESSING BARRIERS (cost via PhilHealth, transport, respectful facilities) — not coercion or dismissal of culture.
Last minute tips
- MLE will test your understanding of the MIDWIFE'S ROLE in TBA integration, not whether TBAs should be eliminated. The answer is always about COLLABORATION, TRAINING, SUPERVISION, and TURNING TBAs INTO REFERRAL PARTNERS. If an MLE scenario asks how you would work with a hilot, show respect, clear communication, and partnership.
- Know the CITATION: AO 2008-0029 ('Implementing Health Reforms for the Rapid Reduction of Maternal and Neonatal Mortality') and MNCHN are the policy anchors. When asked about DOH position on facility-based delivery or TBA role, cite these. The MLE favours exam-takers who know the official policy source.
- Never say a TBA can 'deliver a normal baby' — the DOH policy says NO. Midwife conducts normal deliveries; TBA refers. Common MLE trap: a question says 'The hilot delivers the baby at home with no complications — is this appropriate?' Answer: NO — facility-based policy, no home delivery by TBA, even if low-risk.
- Remember the REFERRAL CHAIN is TWO-WAY and DOCUMENTED. A one-way referral (TBA sends woman to RHU, no feedback) is incomplete. The MLE will ask about follow-up and feedback; show that you close the loop and inform the TBA of outcomes — this maintains trust and improves future referrals.
- When answering about facility-based-delivery ADVOCACY, include THREE elements: (1) respect for culture and woman's autonomy, (2) address barriers (cost via PhilHealth, transport via community plan), (3) involve the TBA as a partner, not an adversary. MLE questions on this topic reward holistic, empathetic answers, not just 'refer to facility.'
Comparison tables
TBA vs. Skilled Birth Attendant (SBA) — Scope Comparison
| Task / Skill | TBA (Hilot) | Midwife (SBA) — RA 7392 Scope |
|---|---|---|
| Identify pregnant women & case-finding | YES — major role | YES — part of ANC integration |
| Conduct prenatal checks (BP, weight, urine) | NO — not trained | YES — standard ANC |
| Counsel on facility birth & danger signs | YES — encouraged | YES — professional duty |
| Conduct normal labour & delivery | NO — DOH policy prohibits | YES — primary scope under RA 7392 |
| Give oxytocics (e.g., oxytocin for bleeding) | NO — not trained or authorised | YES — first-line management |
| Administer magnesium sulphate | NO — not trained | YES — loading dose (refer for ongoing supervision) |
| Manually remove retained placenta | NO — high risk of infection/uterine perforation | YES — signal BEmONC function |
| Recognise danger signs (e.g., seizures, severe bleeding) | YES — after training, BUT cannot manage | YES — recognise AND manage OR refer |
| Refer to midwife or hospital | YES — essential role | YES — when beyond scope |
| Accompany labouring woman to facility | YES — encouraged for continuity | N/A — already at facility |
| Provide emotional/cultural support in labour | YES — labour companion role | YES — part of respectful care |
BEmONC vs. CEmONC — Facility Level Comparison
| Feature | BEmONC (Basic Facility) | CEmONC (Comprehensive Facility) |
|---|---|---|
| Typical Level | RHU, BHS, District Health Office | District/Provincial Hospital |
| Skilled staff | Midwife, nurse, health officer | Obstetrician, anaesthetist, paediatrician, general surgeon |
| Oxytocics, antibiotics, anticonvulsants | YES — signal functions | YES — plus more drugs |
| IV access, blood transfusion | Limited or referral | YES — full blood bank |
| Assisted vaginal delivery (vacuum/forceps) | YES — trained midwife | YES — doctor |
| Neonatal resuscitation | YES — bag & mask, warming | YES — plus intensive care (NICU) |
| Caesarean section / Surgery | NO — refers for this | YES — operating theatre available 24/7 |
| Manual removal of placenta | YES — signal function | YES — routine |
| Who receives referrals? | FROM TBA & community, TO hospital | FROM BEmONC facilities |
Referral Triggers: When to Refer from Midwife to Physician/Hospital
| Clinical Situation | Midwife's Action (BEmONC Scope) | Referral Indication? |
|---|---|---|
| Normal labour, 38 weeks, cephalic, all checks normal | Attend delivery, manage third stage with oxytocin | NO — manage at RHU |
| Vaginal bleeding in labour, BP stable, 500 mL estimated loss | Give oxytocin/ergot, monitor closely, IV access | NO if bleeding stops and BP stable; YES if ongoing/shock |
| Severe headache + blurred vision + BP 160/110 at term | Stabilise: give magnesium sulphate loading dose, monitor | YES — refer to CEmONC immediately (eclampsia risk) |
| Woman with fever + foul vaginal discharge in labour | Start IV antibiotics, IV fluids, monitor vital signs | YES — refer to hospital for ongoing care (sepsis risk) |
| Baby born but placenta not delivered after 30 minutes, bleeding minimal | Give oxytocin, gentle traction on cord, consider manual removal | NO if placenta delivered and bleeding controlled; YES if signs of shock/rupture |
| Breach presentation in labour at 39 weeks | Assess carefully; usually need doctor involvement | YES — refer to hospital (needs doctor/operating theatre ready) |
| Postpartum bleeding 1000 mL, woman dizzy, BP 90/60 | IV access, oxytocin, IV fluids, call ambulance NOW | YES — EMERGENCY referral (shock, likely needs transfusion/surgery) |
Diagrams
TBA Integration & Referral — Complete Concept Map
A comprehensive mind map showing the interconnected concepts of TBA integration: who TBAs are, why policy changed to facility-based delivery, the TBA's redefined role, the midwife's supervisory and collaborative responsibilities, the functional referral chain, the clinical rationale for facility birth, and the advocacy approach that respects culture while promoting safety.
Referral Flowchart: From Community to Skilled Care
A detailed flowchart mapping the patient journey from TBA identification through the referral system. Shows decision points at each level (ANC screening, labour onset, complication detection) and emphasizes that referral is two-way, with feedback returning to the TBA and community, which reinforces trust and improves future case-finding and referral.
Midwife's Supervisory Role With TBAs — Action Steps
A structured flowchart showing the midwife's four core responsibilities (TRAIN, SUPERVISE, COLLABORATE, RECEIVE REFERRALS) and how they work together with facility-birth advocacy to build a functioning community MCH system. Demonstrates that the midwife's role is proactive leadership, not passive reception of referrals.
TBA Integration State Transitions — From Policy to Practice
A state diagram showing how TBA integration progresses from policy initiation (AO 2008-0029) through training, community mobilisation, referral, management, and feedback loops. Illustrates that effective integration is a continuous cycle of training → referring → managing → feeding back → strengthening trust.