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

The hilot, also known as komadrona or mananabang, is a traditional birth attendant—typically an older woman in the community who has learned childbirth assistance through apprenticeship, custom, and accumulated experience rather than formal health-professional training. The hilot holds several powerful assets: deep community trust built over years or decades, fluency in the local language and dialect, understanding of cultural practices and values around pregnancy and birth, and physical presence in remote barangays where skilled health providers are scarce or absent. In many rural and island communities, the hilot is often the *only* person available when a woman goes into labour. This reach and cultural authority make the TBA a valuable asset for community health systems. However, the limitation is critical: a hilot, without formal training in obstetrics or emergency care, cannot reliably recognise or manage obstetric complications. The leading direct causes of maternal death—postpartum haemorrhage (PPH), hypertensive emergencies (eclampsia), obstructed or prolonged labour, sepsis, and complications of unsafe abortion—can emerge suddenly in a labour that appeared normal. These emergencies kill within minutes to hours, and they require skilled intervention: rapid recognition, first-line drugs (oxytocics, magnesium sulphate, antibiotics), and often emergency referral to a facility. The hilot's limitation is not one of caring or intention; it is one of training and resources. This is why current DOH policy mandates that every birth be attended by a Skilled Birth Attendant (SBA)—a doctor, nurse, or midwife—in a facility capable of managing or rapidly referring emergencies.

For decades, the Philippines struggled with one of the highest maternal mortality ratios in Southeast Asia. Large numbers of maternal deaths occurred in home settings attended by non-skilled providers or unattended births. The global evidence is unambiguous: every maternal death is a tragedy, and most are preventable. The leading preventable causes—haemorrhage, infection, hypertensive emergencies, obstructed labour, and unsafe abortion complications—almost all require skilled intervention to reverse. This evidence drove the DOH and the Philippines government to adopt a decisive policy reform: shift from home-based, TBA-attended delivery to facility-based delivery by a Skilled Birth Attendant. The landmark policy is commonly cited as **Administrative Order (AO) 2008-0029**, titled 'Implementing Health Reforms for the Rapid Reduction of Maternal and Neonatal Mortality,' issued by the DOH in 2008. This AO explicitly endorsed a facility-based model and began phasing out routine home-based TBA deliveries. The policy is further reinforced by the DOH's **Maternal, Newborn and Child Health and Nutrition (MNCHN)** strategy and the development of **Basic Emergency Obstetric and Newborn Care (BEmONC)** and **Comprehensive Emergency Obstetric and Newborn Care (CEmONC)** networks. A **BEmONC facility** (typically a Rural Health Unit, hospital, or birthing centre) can provide basic emergency care: delivery by a skilled attendant, oxytocics for PPH, antibiotics for infection, magnesium sulphate for eclampsia, and referral. A **CEmONC facility** (usually a provincial or tertiary hospital) adds surgical capability, including caesarean section and blood transfusion. The referral chain links these facilities so that a case exceeding BEmONC scope can be escalated swiftly. This network model is the operational backbone of skilled-attendant delivery policy. The message for the MLE is clear: the DOH does **not** endorse routine home deliveries by TBAs; it mandates facility birth by a skilled attendant, with referral networks ready to manage or escalate emergencies.

Under current DOH policy, the trained TBA is no longer a 'birth attendant' in the sense of conducting deliveries independently. Instead, the TBA becomes a **bridge to skilled care**—a mobiliser, case-finder, motivator, and referral partner. This redefinition preserves the hilot's community standing while redirecting her efforts toward connecting women to skilled services. The legitimate, evidence-supported roles of a trained TBA include: (1) **Case-finding and identification**: The TBA, embedded in the community, identifies pregnant women early and reports them to the midwife or health worker, ensuring no pregnancy is missed. This is crucial in remote areas where pregnant women may not self-report or may not know where to access care. (2) **Motivation and counselling**: The TBA explains to the pregnant woman and her family why facility-based delivery is safer, addresses fears about the facility or the midwife, and helps the family overcome cultural or logistical barriers to prenatal care and facility birth. The TBA's trust is the vehicle for this persuasion. (3) **Referral and accompaniment**: When labour begins, the TBA does *not* stay to conduct the delivery; instead, she ensures the woman is transported to the midwife or facility. Crucially, the TBA *accompanies* the woman during labour and birth—providing cultural comfort, interpreting language, supporting modesty practices, and being a familiar presence. This role as a labour companion is valuable and does *not* require clinical knowledge; it requires presence and empathy. (4) **Health promotion**: The TBA reinforces key health messages on breastfeeding, newborn care, immunisation, contraception, and danger-sign recognition. She may conduct postnatal follow-ups in the community, checking on mother and baby after facility discharge. (5) **Liaison and feedback**: The TBA maintains communication between the community and the midwife, reporting back to families on results of referrals and helping the midwife understand community concerns or barriers. What the trained TBA is **explicitly not** to do: conduct vaginal deliveries independently, manage labour complications, or attempt any clinical intervention (suturing, administering injections, managing bleeding) without a skilled provider's direct supervision. Some LGUs have enacted local ordinances prohibiting or penalising home deliveries by TBAs, reflecting this policy direction. The midwife's role is to ensure that the trained TBA understands these boundaries clearly and is supported—not marginalised—in the new role.

As a registered midwife under RA 7392, you are the **skilled anchor** for TBAs in your catchment area—whether you work in a Rural Health Unit, a barangay birthing centre, a lying-in clinic, or through a community midwifery programme. Your supervisory and collaborative responsibilities are foundational to making TBA integration work safely and sustainably. **Training and orientation**: Your first responsibility is to train TBAs in the redefined role. This is not a one-time workshop; it is an ongoing partnership. Training should cover: (1) the clinical rationale for facility-based delivery and why skilled attendance saves lives; (2) how to recognise danger signs in pregnancy and labour (vaginal bleeding, severe headache, seizures, severe abdominal pain, labour not progressing); (3) how and when to refer—the protocol for contacting you or the facility, the information to communicate, and how to arrange transport; (4) how to accompany a woman without providing clinical care; (5) the ethical and legal boundaries of the TBA's role and penalties for practising beyond scope; (6) how to communicate with families about facility birth in ways that respect culture and address fears. **Supervision**: Maintain regular, respectful contact with TBAs in your area. This includes periodic visits to their homes or community gathering points, review of their referral data, feedback on cases they have identified and referred, and a forum for them to raise questions or concerns. Supervision is **not** punitive oversight; it is collaborative quality assurance. If a TBA has made an error (e.g., attempted to manage a complication, or delayed a referral), address it educationally: what was the thinking, what information was missing, how can we prevent it next time? A TBA who feels criticised or dismissed will disengage; one who feels supported and valued will stay engaged with the system. **Receiving and managing referrals**: When a TBA refers a case to you—whether a pregnant woman for prenatal care, a labouring woman, or a complication—receive her professionally, note the information she provides, and give her feedback once the case is resolved. Document all referrals. If the TBA accompanied the woman, debrief together to discuss the outcome and any learning points. If your case is beyond your scope (e.g., a woman with pre-eclampsia requiring magnesium sulphate and intensive care), you refer upward to a BEmONC or CEmONC facility and keep the TBA informed. Two-way communication closes the loop and reinforces the TBA's role in the system. **Integration into the community MCH team**: The TBA should not work in isolation. Integrate her into the broader community health structure: link her with the Barangay Health Workers, the midwife, the midwifery student (if your area has a midwifery school placement), and the barangay official. Regular team meetings (monthly or quarterly) allow information-sharing, joint problem-solving, and mutual support. For example, if several pregnant women are not attending prenatal care, the team can brainstorm barriers and solutions together. **Advocacy for facility-based delivery**: Use your clinical authority and credibility to persuade families that facility birth is safer and preferred. Speak clearly about the risks of home delivery, the reality of obstetric emergencies, and how a facility provides rescue. However, also listen: if families cite cost, distance, or disrespect at the facility as barriers, acknowledge these and work to address them. Advocate for subsidies, transport systems, and staff training on respectful maternity care. The midwife who can say, 'Facility birth is safest *and* we will help you overcome the barriers,' wins trust. **Cultural competence**: Learn the local language if you can, understand local beliefs about pregnancy and birth, and incorporate them where safe. For example, if the community values the presence of female relatives during labour, ensure your facility accommodates them. If women fear a male provider, ensure a female midwife or nurse is available. This is not compromise on safety; it is safety delivered with cultural respect.

Referral is the lynchpin that makes TBA integration safe. A referral is the systematic process of transferring a patient from one level of care to another (or from community to facility) for management beyond the capabilities of the first provider. In the context of TBA integration, the referral chain typically flows as: **TBA identifies a case (pregnant woman or labour) → refers to midwife at RHU or birthing centre → midwife manages or escalates to hospital → hospital physician provides higher-level care → feedback returns to midwife and TBA.** For referral to function, it must have three key features: **(1) Timely**: A referral must occur early enough that the receiving facility can intervene before complications become irreversible. For example, a woman with severe pre-eclampsia and no labour must be referred before seizures occur; a woman in obstructed labour must be referred before uterine rupture or foetal death; a woman with haemorrhage must be referred before she becomes moribund from blood loss. Delays are dangerous. (2) Two-way**: The referral is not 'refer and forget.' The midwife at the receiving level provides feedback to the referring TBA or midwife: what was the diagnosis, what was the treatment, what was the outcome? This feedback serves several purposes: it validates the referring provider's clinical judgment, it teaches the referring provider about the case and how to recognise similar cases sooner, and it maintains the relationship and trust that keeps referrals flowing. (3) Documented**: Every referral is recorded in writing—a referral note travels with the patient and documents the reason for referral, vital signs and clinical findings at the time of referral, any interventions already given, and relevant clinical history. The receiving facility documents receipt, clinical findings, diagnosis, and outcome. Both notes are filed so that the referral chain is traceable and can be audited for quality. **The referral form and protocol**: In most Philippine health systems, the referral form is a simple, one-page document asking for: patient name and age, address, chief complaint or reason for referral, obstetric history (gravidity, parity, gestational age), vital signs (BP, pulse, temperature), abdominal findings, vaginal bleeding or discharge, contraction pattern if in labour, and any interventions already given (e.g., oxytocin, antibiotics, IV fluids). The form is signed by the referring midwife or TBA, dated, and timed. A contact number for the receiving facility is noted. The patient or her companion carries the form. In urgent cases (e.g., severe bleeding, seizures, non-vertex presentation in labour), the midwife telephones ahead to the hospital to alert them and ensure a bed and a physician are ready. **Referral for labour and delivery**: When a TBA identifies that a woman is in labour (regular contractions, vaginal blood-stained mucus, rupture of membranes), the TBA does not conduct the delivery. Instead: (a) The TBA assesses readiness for transport: Are there danger signs right now (severe bleeding, convulsions, coma) that require immediate referral? If yes, arrange transport urgently and call ahead. (b) The TBA arranges transport to the RHU or birthing centre where the midwife will be. (c) The TBA accompanies the woman and provides the referral note (either hand-written by the midwife at a prior antenatal visit or written by the TBA based on what she observes). (d) The midwife at the RHU or facility takes over clinical care: assessment of labour progress, foetal status, maternal vitals, and provision of partograph documentation. If labour is normal, the midwife conducts the delivery. If complications appear (labour not progressing, foetal distress, abnormal bleeding), the midwife provides first-line interventions (oxytocin for augmentation, antibiotics for prolonged rupture of membranes, etc.) and escalates to hospital. (e) The TBA may remain as a labour companion if the woman wishes. (f) After delivery and a period of observation (at least 2 hours for a normal vaginal delivery to monitor for immediate complications), the mother and baby are either sent home with a postnatal plan or referred to hospital if complications develop. The midwife sends written feedback to the TBA on the outcome. **Referral for antenatal conditions**: If a pregnant woman is identified by a TBA as having risk signs (severe headache, visual changes, abdominal pain, vaginal bleeding, swelling, reduced foetal movement), the TBA refers her to the midwife without delay. The midwife assesses and either manages the case (e.g., iron supplementation for mild anaemia) or refers upward to the hospital (e.g., magnesium sulphate and ICU care for severe pre-eclampsia). **Emergency referral and legal protection**: In obstetric emergencies—massive bleeding, eclampsia, uterine rupture, foetal distress—every moment counts. The law protects emergency referral: Under the **Anti-Hospital Deposit Law (RA 8344, as amended by RA 10932)**, a hospital **cannot demand a deposit or payment before providing emergency obstetric care**. If a midwife is referring a woman with life-threatening complications and the hospital requests payment upfront, the midwife can invoke this law. This legal protection ensures that financial barriers do not delay emergency care. **Documentation and audit**: All referrals should be recorded in a register (e.g., 'Referral Register' in the RHU) by date, name, reason for referral, receiving facility, and outcome. Quarterly review of this register helps identify patterns: Are certain types of cases referred frequently? Are outcomes good? Are there delays? The audit drives quality improvement. **Common barriers to referral and solutions**: (1) **Transport**: The woman cannot reach the facility because she has no money or transport. Solution: Pre-arranged community emergency-transport plan (a barangay vehicle, incentive for a driver, or subsidy through PhilHealth). (2) **Awareness**: The TBA or family does not recognise a danger sign and delays referral. Solution: Regular TBA training and a clear, simple danger-sign chart (e.g., 'Refer immediately if bleeding, severe headache, seizures, abdominal pain, or labour not progressing'). (3) **Facility quality**: The family fears the hospital or does not respect the midwife there. Solution: Midwife advocacy, facility improvements (respectful staff, clean environment, private rooms if possible), and the midwife or TBA accompanying the woman to the facility. (4) **Trust in the referral system**: The TBA has referred cases before but received no feedback, and feels the effort is unappreciated. Solution: Two-way communication—always tell the TBA what happened to the patient she referred.

The TBA policy sits at the intersection of three important values: cultural respect, community rights, and patient safety. These values sometimes appear to conflict, and the MLE-ready midwife must understand the tensions and be able to navigate them professionally. **The cultural and community perspective**: In many Filipino communities, childbirth is a significant cultural and family event. Traditional practices—the presence of female relatives, specific foods or rituals, the valued role of the older, experienced woman (the hilot)—are woven into the community's identity and values. To families, suggesting that birth must happen in a facility with 'outsiders' (a young midwife, a clinical environment) can feel like an erasure of identity and a devaluation of community knowledge. When a local ordinance penalises home births, the impact is felt acutely: it can feel like the state is punishing the poor for not having access to what the rich take for granted (a facility birth). This creates resentment and can drive births underground—into completely unattended home settings, which is worse for safety. **The patient-safety perspective**: The clinical reality is unambiguous: obstetric emergencies are unpredictable and lethal. A woman with a 'normal' pregnancy and labour can deteriorate to life-threatening status within minutes: massive bleeding, seizures, obstructed labour with foetal distress. The only proven intervention is rapid access to skilled care and emergency facilities. Home delivery, even with a trained TBA present, cannot provide this. The data from low-income countries is consistent: skilled, facility-based delivery reduces maternal and neonatal mortality. To a health professional, prioritising access to skilled care is not cultural insensitivity; it is the standard of care—what every mother and baby deserves. **The balancing approach—'both/and' rather than 'either/or'**: The professionally sound midwife does not choose between culture and safety; she works to deliver safety **with** cultural respect. This means: (1) **Advocacy rooted in education, not coercion**: Explain clearly and respectfully why facility birth is safer and what can go wrong. Speak to families, not at them. Listen to their fears and address them specifically—'Are you worried about the cost? We have PhilHealth. Are you worried about disrespect? We will ensure you are treated with respect and your family is welcome. Are you worried about unfamiliar practices? Let me explain what will happen.' (2) **Remove barriers, not just enforce rules**: If the main barriers are cost, distance, or facility quality, address them. Work with the municipality to subsidise transport or establish a pre-arranged emergency-transport vehicle. Ensure PhilHealth's free Maternity Care Package is well-publicised and accessible. Push for facility improvements: respectful staff, privacy, cultural accommodation (female provider if preferred, family presence during labour, postpartum rooming-in). A rule that says 'You must deliver at a facility' without removing the barriers that make facility delivery inaccessible or unwelcoming is, frankly, unjust. (3) **Preserve the TBA's role and respect**: The TBA does not disappear; her role evolves. A skilled, respected older woman remains valuable as a mobiliser, health promoter, and labour companion. Compensation, recognition, and inclusion in the health system validate her and make the transition sustainable. Communities that lose the hilot entirely feel the loss; communities that transform the hilot's role feel continuity. (4) **Respect cultural practices within safety boundaries**: If families value female relatives present during labour, accommodate them (within reason; the midwife still needs access to the woman's abdomen and perineum). If families value specific foods or rituals after delivery, support them as long as they don't interfere with breastfeeding or postnatal care. Many cultural practices are compatible with safe, skilled care; the goal is integration, not erasure. (5) **Evidence-based persuasion**: Use local data. If there are maternal or neonatal deaths in the area linked to home delivery, present this data respectfully to the community. If there is a positive story—a woman who delivered safely at the facility, a baby who was resuscitated and survived—share it. Communities respond to local evidence more than to national statistics. **The ordinance debate**: Some LGUs have enacted ordinances penalising or restricting home births. The intent is patient safety, but the effect can be counterproductive if barriers remain. The evidence suggests that punitive ordinances, without parallel investments in removing barriers, lead to hidden births (women delivering at home and not reporting, forgoing antenatal and postnatal care) rather than facility births. A more effective ordinance combines incentives (free transport, free facility care, incentive for TBAs who refer) with clear, supported prohibition (home births by non-skilled attendants). The midwife's role is to advocate for this balanced approach in policy discussions. **Building trust through presence and follow-up**: Ultimately, the persuasion is not an argument; it is a relationship. When a midwife is visible in the community, available, respectful, and competent, mothers choose facility birth because they trust the midwife. When the midwife provides good postnatal care and breastfeeding support, word spreads. When the midwife celebrates the hilot's contributions and works collaboratively, the community sees alignment, not conflict. Trust is built over time, not overnight. **Summary principle**: The midwife's stance is: 'Facility birth with skilled care is the safest, and it is accessible, affordable, respectful, and compatible with our community's values. Let us work together to make that happen for every mother and baby.'

The legal and regulatory foundation for TBA policy and midwife scope rests on several key instruments. **Republic Act 7392 (RA 7392): The Midwifery Act**: RA 7392, enacted in 1992, established the practice of midwifery as a regulated profession in the Philippines and defined the scope of practice of registered midwives. The key points relevant to TBA integration are: (1) A registered midwife is 'a professional health worker with scientific knowledge and practical skills in the management of pregnancy, labour, delivery, and the immediate postpartum period, as well as in family planning and community health.' (2) The midwife is an **independent primary provider** of normal maternal, newborn, and family-planning care. This means the midwife does not need a physician's prescription or presence to deliver a woman with a normal, uncomplicated pregnancy and labour; she is authorised by law and by her training to manage these cases. (3) The midwife **recognises complications and refers them to appropriate care**—a physician in a hospital. The law does not authorise midwives to manage complications (such as caesarean delivery, manual removal of placenta in a non-delivery setting, or surgical procedures); instead, midwives are trained to detect danger signs and refer rapidly. (4) RA 7392 also specifies that midwives cannot practise (i.e., are not licensed) to engage in activities outside their scope, and that TBAs are **not licensed healthcare providers**—they are community members assisting with childbirth based on custom and experience, not formal professional training. **Administrative Order 2008-0029**: This AOissued by the Department of Health, is titled 'Implementing Health Reforms for the Rapid Reduction of Maternal and Neonatal Mortality' and is one of the highest-level policy documents endorsing facility-based, skilled-attendant delivery. It explicitly directs the health system toward: (1) **BEmONC and CEmONC networks** — establishing and strengthening Basic and Comprehensive Emergency Obstetric and Newborn Care facilities linked by referral protocols. (2) **Skilled birth attendance for every delivery** — ensuring that every birth is attended by a doctor, nurse, or midwife in a facility equipped to manage or refer emergencies. (3) **Reorienting the role of TBAs** — phasing them out of delivery and integrating them as community partners in case-finding, motivation, and referral. (4) **Capacity-building** — training midwives, strengthening facilities, and establishing emergency transport systems. **DOH Maternal, Newborn and Child Health and Nutrition (MNCHN) Strategy**: The MNCHN is the over-arching national strategy for reducing maternal, newborn, and child mortality. It incorporates facility-based delivery, skilled attendance, BEmONC/CEmONC networks, and community health-worker engagement (including TBAs) into a comprehensive system. The MNCHN reinforces the message: **every birth should be attended by a skilled provider in a facility capable of managing or referring emergencies.** **Local Ordinances and TBA Regulations**: Many municipalities and cities have enacted local ordinances addressing TBA practice and home delivery. These ordinances vary widely: some prohibit non-skilled home deliveries, some require TBAs to be trained and registered, some establish TBA committees with midwife oversight, and some provide incentive pay or supplies for TBAs who refer. As a midwife, you should know the ordinance in your jurisdiction and help ensure it is applied fairly and coupled with barrier-removal strategies (as discussed in section 6). **The Anti-Hospital Deposit Law (RA 8344, as amended by RA 10932)**: This law is critical for referral protection. RA 8344, originally enacted in 1997, prohibited hospitals from demanding deposits before providing emergency care. RA 10932, enacted in 2016, amended RA 8344 and strengthened protections further. The core provision: **a hospital cannot demand a deposit, payment, or security before admitting and providing initial management of a patient presenting with a medical emergency**, including obstetric emergencies. This protects referrals from mid-level facilities (RHUs, lying-in clinics) to hospitals, ensuring that financial barriers do not delay emergency care. A midwife referring a bleeding or seizing mother can invoke this law if the hospital demands payment first. **Implementing Rules and Regulations (IRRs) and Administrative Guidelines**: Various DOH issuances and guidelines operationalise these laws and orders. For example, the DOH has issued guidelines on BEmONC certification, TBA training standards, referral protocols, and the role of midwives in health facilities and communities. As a registered midwife, familiarising yourself with these guidelines ensures your practice aligns with the latest policy and standards. **International Alignment**: The Philippines' TBA policy aligns with international standards set by the World Health Organization (WHO) and the International Confederation of Midwives (ICM). WHO defines a Skilled Birth Attendant as 'an accredited health professional (doctor, midwife or nurse) who has been trained to proficiency in the knowledge, technical skills and behaviour required to manage normal pregnancies, childbirth and the immediate postpartum period, and in the identification, management and referral of complications in women and newborns.' This definition, adopted by the Philippines and global health systems, explicitly excludes TBAs who lack formal training. The midwife, under RA 7392 and international standards, is the Skilled Birth Attendant who bridges the gap between community and facility care.

Understanding the policy is the foundation; implementing it in a real community is the test. This section outlines the practical steps a midwife can take to build a functional, sustainable TBA integration system in her catchment area. **Step 1: Baseline assessment and mapping**: Before you can supervise or train TBAs, identify who they are and what they are currently doing. Conduct a simple baseline survey: visit the barangays in your catchment, ask barangay officials and health workers who the active TBAs are, visit them, and listen. Ask: How many births has she attended in the past year? Is she trained in any specific skills (e.g., clean delivery, newborn resuscitation)? Does she know about danger signs? Is she willing to participate in training? This information helps you prioritise and tailor your approach. Map the community: Where do pregnant women live? How far from the RHU? What transport is available? Where are the barriers? A simple hand-drawn map on the barangay wall showing homes, the health station, the RHU, and the hospital helps visualise the referral chain. **Step 2: Design and deliver training**: Develop a short, practical training for TBAs on their new role. A one-day or two-day training might include: (1) Why facility birth is safer (case studies or videos of obstetric emergencies and outcomes). (2) How to recognise danger signs: teach a simple, memorable list—'Red flags: bleeding, severe headache, seizures, abdominal pain, labour not progressing.' Provide pictorial danger-sign charts (useful if TBAs are not literate). (3) How to refer: teach the referral process step-by-step, including what information to communicate, how to arrange transport, and how to fill a referral form (simple, large print). (4) Role in labour: explain that the TBA's role is to accompany, comfort, and support—not conduct the delivery. Give examples of what this looks like. (5) Ethical and legal boundaries: explain that the TBA who conducts deliveries without authority faces legal consequences (depending on local ordinance), but the TBA who refers gets recognition and support. Use local language and simple explanations. Involve other TBAs who have already accepted the new role (peer influence). Provide a certificate of attendance and, if possible, a small honorarium or gift—this validates the TBA's participation. **Step 3: Establish two-way referral communication**: Set up a simple referral system. This might include: (1) A referral form (hand-written or printed) that the TBA or midwife can use to document the case and send with the patient. (2) A log or register at the RHU where the midwife records all referrals received (date, source—TBA or community, reason, outcome). (3) A monthly report: the midwife summarises referral data and shares it with TBAs at a community meeting—'We received 12 referrals last month, 8 for antenatal care, 4 for labour. All mothers and babies are well.' (4) A feedback mechanism: when a case is resolved, communicate the outcome back to the referring TBA (preferably verbally if the midwife visits the barangay, or through a written note if not). **Step 4: Integrate TBAs into the community MCH team**: Do not isolate TBAs; bring them into the broader team. This might include: (1) **Quarterly community health-worker meetings**: invite TBAs, Barangay Health Workers, the midwife, and the barangay official. Agenda: review maternal/neonatal health data, discuss barriers and solutions, celebrate successes, and plan for the coming quarter. (2) **Assign a TBA a specific barangay or zone**: give each TBA clear accountability—she is responsible for identifying all pregnant women in her zone, ensuring they get prenatal care, and referring them to the midwife for delivery. (3) **Create a role for the TBA in postnatal care**: after a woman delivers at the facility, the TBA can follow up at home (with guidance from the midwife) and check on breastfeeding, newborn danger signs, and family-planning interest. This maintains the TBA's valued role in the postpartum period and keeps mothers connected. (4) **Recognise and support TBAs**: a small monthly honorarium (even PHP 500–1000 per month, funded by the municipality or health programme), a vest or armband identifying her as a trained TBA, and public recognition at barangay meetings—all these validate the role and improve motivation. **Step 5: Establish a community emergency-transport plan**: Referral only works if the woman can physically reach the facility. Work with the barangay to establish: (1) A designated vehicle or motorcycle available for emergencies. (2) An identified driver (or drivers on rotation) with a phone number known to TBAs and families. (3) A protocol: when a woman is in labour or an emergency occurs, the TBA or family calls the driver, who collects the patient and takes her to the RHU or hospital. (4) A funding mechanism: the municipality may allocate petty cash for fuel, or a PhilHealth co-financing mechanism may cover transport. (5) A practice drill: periodically, practise the transport system so that when an actual emergency occurs, everyone knows what to do. **Step 6: Improve facility readiness and respectful care**: If the RHU or hospital is not welcoming, women will avoid it. Ensure: (1) Adequate staffing so that the midwife is not overwhelmed and can provide attentive care. (2) Respectful, kind staff training: many women fear facilities because of rude interactions. A half-day staff training on respectful maternity care (listening, speaking in the local language, involving the family, minimising unnecessary restrictions) transforms the experience. (3) Accommodation of cultural practices: allow female relatives during labour, permit specific foods or rituals post-birth, ensure privacy and dignity. (4) Breastfeeding support: a lactation consultant or trained midwife available to help mothers initiate and sustain breastfeeding. (5) Cleanliness and equipment: basic supplies (clean delivery packs, oxytocin, antibiotics, magnesium sulphate for BEmONC facilities, resuscitation equipment), clean rooms, and handwashing stations. **Step 7: Advocate for barrier removal**: Working closely with TBAs and community, identify specific barriers to facility birth and systematically address them: (1) **Cost**: ensure families know about PhilHealth's free Maternity Care Package. Provide enrollment support and direct admission to PhilHealth-accredited facilities. (2) **Distance**: establish monthly antenatal clinics in remote barangays (midwife travels out) to reduce the need for women to travel far for prenatal care. Ensure a pre-arranged emergency-transport plan so that distance does not become a barrier during labour. (3) **Facility quality**: listen to community feedback and make improvements. If women fear rudeness, train staff. If they fear lack of privacy, rearrange the delivery room. If they fear costs despite PhilHealth, simplify and publicise the exemption. (4) **Cultural fit**: ensure the facility respects cultural practices and involves families. Some communities prefer female providers; ensure female midwives and nurses are available. (5) **Communication**: ensure women understand what will happen at the facility and why, reducing fear and surprise. The TBA's role in explaining and demystifying the facility is crucial. **Step 8: Monitor and adjust**: After 6 months of implementation, review outcomes: (1) How many pregnant women were identified by TBAs? (2) What percentage attended prenatal care? (3) What percentage delivered at a facility with skilled attendance? (4) How many referrals were made, for what reasons, and what were the outcomes? (5) Were there any maternal or neonatal deaths? If yes, was it preventable? (6) Are TBAs satisfied with their role? Are they engaged or disengaged? (7) What barriers persist? Use this data to adjust the system. If prenatal attendance is low, work harder on motivation and access. If referrals are delayed, strengthen danger-sign recognition training. If facility quality is the barrier, invest in facility improvements. **Step 9: Scale and institutionalise**: Once the system is working in one barangay, expand to others. Build it into the RHU's annual plan, secure municipal budget allocation, and establish it in policy so it is not dependent on one midwife's initiative. A sustainable system is built into the organisation and the community, not held together by one individual.