Midwife Licensure Exam Midwifery Law, Scope & Community Role (RA 7392) — Traditional Birth Attendant (Hilot) Integration & ReferralConcept Map

Concept

Who is the Hilot/TBA

Sub Concepts

• Community-embedded figure
• Non-formal training (apprenticeship, custom, experience)
• Deep community trust and cultural knowledge
• Physical presence in remote barangays
• Cannot recognize or manage obstetric complications

Relationship To Central

Defines the traditional birth attendant's identity and current role within the health system

Concept

Policy Shift: From Home Birth to Facility-Based Delivery

Sub Concepts

• High maternal mortality ratio historically
• AO 2008-0029 (Rapid Reduction of Maternal and Neonatal Mortality)
• MNCHN Strategy (Maternal, Newborn and Child Health and Nutrition)
• BEmONC/CEmONC networks
• Skilled Birth Attendant (SBA) requirement
• Evidence-based facility delivery model

Relationship To Central

Justifies the redefinition of the TBA role and establishes the legal and strategic foundation

Concept

TBA's Redefined Role

Sub Concepts

• Case-finding (identifying pregnant women early)
• Motivating prenatal care attendance
• Advocating facility-based delivery planning
• Referring and accompanying to birthing facility
• Labour companion and cultural liaison
• Health promotion and danger-sign education
• NOT conducting deliveries independently
• NOT managing obstetric complications

Relationship To Central

Specifies what TBAs should and should not do under current policy

Concept

Clinical Justification for Facility Birth

Sub Concepts

• Leading direct causes of maternal death
• Postpartum hemorrhage (can appear suddenly)
• Hypertensive disorders (pre-eclampsia/eclampsia)
• Obstructed or prolonged labour
• Sepsis and infection
• Unsafe abortion complications
• Skilled attendant recognition and intervention
• Critical narrow margin for rescue (minutes, not hours)

Relationship To Central

Provides the evidence base explaining why skilled facility attendance is non-negotiable

Concept

Midwife's Supervisory & Collaborative Role

Sub Concepts

• Training TBAs on redefined role
• Orienting on danger signs and referral pathways
• Supervising community activities
• Maintaining respectful working relationships
• Receiving and managing TBA referrals
• Escalating beyond-scope cases to physicians
• Integrating with Barangay Health Workers
• Advocacy for facility-based delivery
• Making safe choice the easy choice

Relationship To Central

Establishes the midwife as the skilled professional anchor managing TBA partnership

Concept

Referral Relationship & System

Sub Concepts

• Two-way referral chain (TBA → Midwife → Physician/BEmONC)
• Timely identification and referral
• Documentation and referral note systems
• Feedback mechanisms from facilities
• Emergency referral protocols
• Transport coordination
• Anti-Hospital Deposit Law (RA 8344, RA 10932)
• Stabilization before transfer
• Communication with receiving facility

Relationship To Central

Describes the operational mechanism that makes TBA integration safe and effective

Concept

Balancing Culture, Rights, and Safety

Sub Concepts

• Safety rationale for facility delivery
• Criticism of penalizing home births
• Barriers: distance, cost, transport
• Coercion vs. enablement approaches
• PhilHealth Maternity Care Package
• Community emergency-transport planning
• Culturally-sensitive facility care
• Advocacy vs. coercion
• Keeping families connected to skilled care

Relationship To Central

Addresses the ethical and practical tensions in TBA policy implementation

Concept

Legal & Regulatory Framework

Sub Concepts

• RA 7392 (Midwifery Law)
• AO 2008-0029
• MNCHN guidelines
• Local ordinances on home delivery
• Anti-Hospital Deposit Law (RA 8344, RA 10932)
• BEmONC/CEmONC standards
• Skilled Birth Attendant definitions
• Professional licensing and scope

Relationship To Central

Provides the statutory and administrative foundation for TBA policy and midwife scope

Concept

Community Integration & Advocacy

Sub Concepts

• Building rapport with families
• Making facility birth culturally acceptable
• PhilHealth enrollment and benefits
• Community emergency-transport plan
• Barangay health team coordination
• Case-finding partnerships
• Post-delivery follow-up integration
• Newborn and maternal follow-up
• Breastfeeding and immunization support

Relationship To Central

Describes strategies to translate policy into effective, accepted practice

To

TBA Redefined Role

From

Who is the Hilot/TBA

Strength

strong

Relationship

The TBA's identity (non-skilled, community-trusted) defines what she can safely do under the new policy (case-finding, referral, accompaniment) and what she must not do (delivery, complication management)

To

TBA Redefined Role

From

Policy Shift: From Home Birth to Facility-Based Delivery

Strength

strong

Relationship

The shift in policy is the direct reason for redefining the TBA's role away from conducting home deliveries toward facility-based referral and accompaniment

To

Policy Shift: From Home Birth to Facility-Based Delivery

From

Clinical Justification for Facility Birth

Strength

strong

Relationship

Clinical evidence of rapid deterioration in labour (hemorrhage, eclampsia, sepsis) justifies the policy mandate that every delivery must be attended by a skilled attendant in a facility with emergency capabilities

To

TBA Redefined Role

From

Midwife's Supervisory & Collaborative Role

Strength

strong

Relationship

The midwife translates policy into practice by training, orienting, and supervising the TBA to ensure she stays within the redefined role boundaries

To

Midwife's Supervisory & Collaborative Role

From

Referral Relationship & System

Strength

strong

Relationship

The functioning referral chain (TBA → Midwife → Physician) is the operational mechanism by which the midwife fulfills her supervisory and collaborative role

To

Community Integration & Advocacy

From

Balancing Culture, Rights, and Safety

Strength

strong

Relationship

The tension between safety, cultural acceptance, and accessibility is resolved through advocacy strategies that enable facility birth (PhilHealth, transport, respectful care) rather than coerce it

To

TBA Redefined Role

From

Community Integration & Advocacy

Strength

moderate

Relationship

TBA collaboration in case-finding, motivation, and accompaniment is a key strategy to translate facility-delivery advocacy into actual practice change in communities

To

Policy Shift: From Home Birth to Facility-Based Delivery

From

Legal & Regulatory Framework

Strength

strong

Relationship

Legislation (AO 2008-0029, MNCHN guidelines, BEmONC standards) provides the statutory and administrative basis for the policy shift toward facility-based skilled attendance

To

Midwife's Supervisory & Collaborative Role

From

Legal & Regulatory Framework

Strength

strong

Relationship

RA 7392 (Midwifery Law) and related regulations define the midwife's scope of practice, professional responsibility, and authority to supervise and receive referrals from TBAs

To

Clinical Justification for Facility Birth

From

Referral Relationship & System

Strength

strong

Relationship

The referral system's emphasis on timely escalation and emergency transfer is directly justified by the clinical reality that maternal complications (hemorrhage, eclampsia) can appear suddenly and require rapid skilled intervention

To

Referral Relationship & System

From

Community Integration & Advocacy

Strength

moderate

Relationship

Effective advocacy (through PhilHealth, community transport, respectful facilities) removes barriers that would otherwise impede women's use of the referral pathway to facility delivery

To

Midwife's Supervisory & Collaborative Role

From

Who is the Hilot/TBA

Strength

moderate

Relationship

Understanding the TBA's strengths (community trust, cultural knowledge) and limitations (lack of formal training, inability to manage complications) shapes how the midwife supervises and partners with her

To

Legal & Regulatory Framework

From

Balancing Culture, Rights, and Safety

Strength

moderate

Relationship

The tension between coercion and enablement is reflected in DOH guidance and local ordinances, with advocacy-based enablement being the preferred professional approach

To

Midwife's Supervisory & Collaborative Role

From

Clinical Justification for Facility Birth

Strength

moderate

Relationship

The midwife's advocacy for facility delivery is grounded in clinical evidence of the dangers of home birth with non-skilled attendants and the life-saving role of skilled care in facility settings