Traditional Birth Attendant (Hilot) Integration & Referral - Concept Map
TBA Integration into the Philippine Maternal Health System
Related concepts
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
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
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
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
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
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
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
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
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
Concept connections
- Who is the Hilot/TBATBA Redefined RoleThe 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)
- Policy Shift: From Home Birth to Facility-Based DeliveryTBA Redefined RoleThe shift in policy is the direct reason for redefining the TBA's role away from conducting home deliveries toward facility-based referral and accompaniment
- Clinical Justification for Facility BirthPolicy Shift: From Home Birth to Facility-Based DeliveryClinical 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
- Midwife's Supervisory & Collaborative RoleTBA Redefined RoleThe midwife translates policy into practice by training, orienting, and supervising the TBA to ensure she stays within the redefined role boundaries
- Referral Relationship & SystemMidwife's Supervisory & Collaborative RoleThe functioning referral chain (TBA → Midwife → Physician) is the operational mechanism by which the midwife fulfills her supervisory and collaborative role
- Balancing Culture, Rights, and SafetyCommunity Integration & AdvocacyThe tension between safety, cultural acceptance, and accessibility is resolved through advocacy strategies that enable facility birth (PhilHealth, transport, respectful care) rather than coerce it
- Community Integration & AdvocacyTBA Redefined RoleTBA collaboration in case-finding, motivation, and accompaniment is a key strategy to translate facility-delivery advocacy into actual practice change in communities
- Legal & Regulatory FrameworkPolicy Shift: From Home Birth to Facility-Based DeliveryLegislation (AO 2008-0029, MNCHN guidelines, BEmONC standards) provides the statutory and administrative basis for the policy shift toward facility-based skilled attendance
- Legal & Regulatory FrameworkMidwife's Supervisory & Collaborative RoleRA 7392 (Midwifery Law) and related regulations define the midwife's scope of practice, professional responsibility, and authority to supervise and receive referrals from TBAs
- Referral Relationship & SystemClinical Justification for Facility BirthThe 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
- Community Integration & AdvocacyReferral Relationship & SystemEffective advocacy (through PhilHealth, community transport, respectful facilities) removes barriers that would otherwise impede women's use of the referral pathway to facility delivery
- Who is the Hilot/TBAMidwife's Supervisory & Collaborative RoleUnderstanding 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
- Balancing Culture, Rights, and SafetyLegal & Regulatory FrameworkThe tension between coercion and enablement is reflected in DOH guidance and local ordinances, with advocacy-based enablement being the preferred professional approach
- Clinical Justification for Facility BirthMidwife's Supervisory & Collaborative RoleThe 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
Diagrams
TBA Integration & Referral: Complete Concept Hierarchy
A comprehensive mind map showing all major concept areas in the TBA integration chapter. The central concept branches into 8 key topic areas: TBA identity, policy foundation, redefined role, clinical justification, midwife's leadership role, referral mechanisms, ethical balance, and legal framework. Each branch further subdivides into specific learning points essential for MLE preparation.
TBA-to-Facility Referral Pathway (Normal Case)
This flowchart traces the complete referral journey from TBA case-finding through skilled delivery and postpartum follow-up. Green nodes highlight TBA activities (case-finding, referral, accompaniment), yellow nodes show midwife-led normal care, and red shows escalation to higher level. It demonstrates the two-way collaboration model and reinforces that the TBA's role is to mobilize, refer, and accompany—not to conduct delivery.
TBA-Midwife-Physician Decision Tree: When to Refer
A clinical decision tree showing the triggers for escalation from TBA/Midwife to physician-level care. Red danger-sign boxes (hemorrhage, eclampsia, sepsis, obstructed labour) denote conditions requiring urgent facility-based emergency care. This reinforces the core MLE principle: midwives recognize complications and refer—they do not attempt to manage them in the community.
Midwife's TBA Supervision & Training Responsibilities
This flowchart outlines the midwife's leadership role in training, supervising, and integrating TBAs into the community health system. It emphasizes that supervision is ongoing, supportive, and performance-based—with regular monitoring of case-finding, referral compliance, and accompaniment quality. The cycle reinforces the midwife's professional responsibility to ensure safe practice within the TBA's defined scope.
TBA Role Transition: From Home Deliverer to Referral Partner
A state diagram showing the evolution of the TBA role from traditional home-based delivery attendant to integrated community health partner. It illustrates the policy-driven transition triggered by evidence of maternal mortality and the shift to facility-based skilled attendance. This helps reviewees understand the historical context and policy rationale underlying current MLE questions.
Removing Barriers to Facility Delivery: Enablement Strategy
This flowchart maps the three major barriers to facility delivery (financial, geographic, cultural) and shows concrete mitigation strategies (PhilHealth package, community transport, respectful culturally-sensitive care). It reinforces the MLE principle that advocacy should address barriers (enablement) rather than rely on coercion. The midwife's role is to make facility birth the easy, trusted default.
Leading Causes of Maternal Death: Clinical Justification for Facility Birth
A pie chart showing the proportional contribution of the leading direct causes of maternal death. Postpartum hemorrhage, hypertensive crisis (eclampsia), sepsis, obstructed labour, and unsafe abortion together account for approximately 81% of direct maternal deaths. Each of these can appear suddenly in a labour that looked normal and requires immediate skilled intervention. This distribution underscores why the DOH insists that even low-risk pregnancies must be attended by a skilled birth attendant in a facility equipped to manage emergencies.