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

A community member—typically an older woman—who assists childbirth using skills learned through apprenticeship, custom, and experience rather than formal health-professional training. In the Philippines, the hilot has been a trusted, culturally-embedded figure in remote barangays for generations. She commands deep community respect, speaks the local dialect, understands cultural birth practices, and is physically present where skilled providers are scarce. However, she cannot reliably recognize obstetric complications (haemorrhage, eclampsia, obstructed labour, sepsis) or provide evidence-based emergency interventions. This gap between trust and capability is the central tension in TBA policy.

A health professional with formal training and competencies to attend normal deliveries and recognize and refer obstetric complications. In the Philippines, SBAs include doctors, nurses, and registered midwives. A skilled birth attendant can recognize danger signs (abnormal bleeding, severe headache, seizures, signs of infection), initiate first-line interventions (administer oxytocics, magnesium sulphate under medical direction, antibiotics), and communicate urgently with a receiving facility for escalation. The evidence base is clear: every birth attended by an SBA in a facility equipped for emergency obstetric care reduces maternal and newborn mortality. This is the foundation of DOH policy.

Administrative Order 2008-0029, 'Implementing Health Reforms for the Rapid Reduction of Maternal and Neonatal Mortality,' represents the DOH's decisive policy shift toward facility-based delivery by a skilled birth attendant. The order anchors a suite of reforms: every birth should occur in a facility, attended by an SBA, with functioning BEmONC (Basic Emergency Obstetric and Newborn Care) and CEmONC (Comprehensive Emergency Obstetric and Newborn Care) networks linked by a working referral chain. TBAs are explicitly repositioned away from conducting deliveries and toward mobilizing and referring pregnant women to skilled care. This policy is reinforced by the broader Maternal, Newborn and Child Health and Nutrition (MNCHN) strategy. The order reflects global evidence and is a cornerstone of Philippine MCH law and practice.

Basic Emergency Obstetric and Newborn Care (BEmONC) and Comprehensive Emergency Obstetric and Newborn Care (CEmONC) form a tiered facility network designed to catch and manage obstetric emergencies. A BEmONC facility (typically a Rural Health Unit, birthing center, or district hospital) can provide essential signal functions: manual removal of retained placenta, parenteral antibiotics, oxytocics, magnesium sulphate, assisted vaginal delivery, basic neonatal resuscitation. A CEmONC facility (typically a tertiary hospital or well-equipped provincial hospital) can additionally perform cesarean section and blood transfusion. The network is *linked* by a functioning referral chain: a midwife at a BHS or RHU recognizes a complication, stabilizes the mother, and refers her urgently to the nearest appropriate BEmONC or CEmONC facility. The TBA, by identifying and referring the pregnant woman early to prenatal care and facility delivery, feeds women into this system at the prevention stage.

Under current DOH policy, the trained TBA's legitimate functions are: (1) Case-finding—identifying and registering pregnant women early in the community; (2) Motivation—encouraging women to attend prenatal check-ups, planning facility delivery, and addressing fears or misconceptions about birthing facilities; (3) Referral—communicating with the midwife when a woman is in labour or has a complication, and escorting her to the facility; (4) Accompaniment—serving as a birth/labour companion, providing culturally-appropriate comfort and support, and acting as a bridge between the family and the healthcare team. The TBA is also expected to reinforce health messages on breastfeeding, newborn danger signs, immunization, and family planning. What the TBA is *not* to do: independently conduct deliveries, manage labour, or attempt to handle obstetric complications. This redefinition preserves the TBA's community standing while redirecting her energy toward safe, skilled care.

The registered midwife is the skilled anchor in the TBA relationship. Her responsibilities include: (1) Training and orientation—teaching TBAs the signs of pregnancy, normal labour, and danger signs (severe bleeding, severe headache, difficulty breathing, convulsions); explaining when and how to refer; clarifying the limits of the TBA role; (2) Supervision—maintaining an open, respectful working relationship; observing community activities; ensuring TBAs are not conducting deliveries; (3) Receiving referrals—seeing the TBA-identified woman for prenatal care, labour management, and normal delivery, or escalating to a physician if complications arise; (4) Integration—involving the TBA in the community MCH team alongside Barangay Health Workers for case-finding, follow-up, and health promotion; (5) Advocacy—persuasively promoting facility-based delivery while respecting cultural practices. The tone is *collaboration*, not confrontation: an alienated hilot may withdraw from the referral system, driving births back underground. A trained, respected, integrated TBA becomes a powerful force for safe delivery.

A functioning referral system is the mechanism that makes TBA integration safe. The chain looks like this: (1) TBA identifies pregnant woman early, refers her to the midwife for prenatal care; (2) Midwife screens, manages normal pregnancy, and plans facility delivery; (3) Woman goes into labour; TBA alerts midwife and accompanies woman to facility; (4) Midwife receives the woman, conducts labour management, and if complications arise, refers urgently to physician/BEmONC/CEmONC; (5) Feedback returns: the receiving facility informs the midwife of the outcome, and the midwife informs the TBA that 'her patient' delivered safely. This *two-way* communication—referral *and* feedback—ensures that the TBA remains engaged and learns that the system works. Referrals must be *documented* (a referral note travels with the patient and a copy remains with the sending provider), *timely* (communicated without delay, especially in emergencies), and *respectful* (the provider who refers is not blamed or dismissed). Emergency transfers are protected by the Anti-Hospital Deposit Law (RA 8344, as amended by RA 10932), which prohibits a hospital from demanding a deposit before providing emergency obstetric care.

The policy insistence on facility-based, skilled-attendant delivery rests on a clinical reality that every midwife must understand and be able to articulate. The leading direct causes of maternal death—postpartum haemorrhage (PPH), hypertensive disorders (pre-eclampsia and eclampsia), obstructed or prolonged labour, sepsis/infection, and complications of unsafe abortion—can appear *suddenly* in a labour that looked entirely normal minutes before. Massive bleeding can occur within seconds of placental delivery; eclamptic seizures can strike without prior headache; uterine rupture or cord prolapse can occur in a woman with no prior risk factors; overwhelming infection can develop rapidly postpartum. These emergencies kill within hours if not managed. A skilled birth attendant in a facility can recognize the warning sign (heavy vaginal bleeding, severe headache, convulsions, signs of shock), give the *first-line intervention* immediately (administer an oxytocic, magnesium sulphate, antibiotics, IV fluids, oxygen), and communicate urgently with a receiving facility so that the woman reaches a physician or CEmONC centre in the critical window. A TBA at home, no matter how experienced or well-intentioned, cannot reliably do this. She may recognize that something is very wrong, but by then precious time has elapsed. This is why the DOH insists that even *low-risk, apparently normal* deliveries occur in a BEmONC-capable facility with an SBA: because risk is unpredictable, and the margin for rescue is measured in minutes, not hours.

Advocacy for facility-based delivery is not coercion. The professionally sound and ethically-grounded approach recognizes that many families—especially in remote or poor communities—want a safe birth but face real *barriers*: cost (clinic fees, transport), distance (no transport, no road), time (working mothers, farming schedules), and mistrust or cultural discomfort with the health facility. The midwife's role is to make the safe choice the *easy* choice by: (1) Building rapport and trust so women *want* to deliver with a skilled attendant; (2) Ensuring the birthing facility is welcoming, clean, respectful of modesty and cultural practices (e.g., allowing birth companions, respecting dietary preferences), and staffed by providers who listen; (3) Linking families to PhilHealth's Maternity Care Package (free facility-based prenatal care, delivery, and postpartum care for indigent and low-income women); (4) Working with barangay officials to establish a community emergency-transport plan ('birth-and-emergency plan')—pre-arranged transport, mutual-aid funds, or a network to ensure that distance does not become a death sentence; (5) Addressing misconceptions and fear through health education and peer testimonies. By contrast, *coercion*—penalizing or shaming families who choose home birth, or enacting ordinances that criminalize TBA deliveries—tends to drive births *underground*, away from any health system contact, or into the hands of unsafe practitioners. Some LGUs have enacted such ordinances, but they are debated on human-rights grounds. The midwife's advocacy focuses on enablement: remove the barriers, and most families will choose safe, facility-based care.

TBA policy is not without tension, and the MLE-ready midwife should understand both the public-health imperative and the legitimate concerns about autonomy and access. On one hand, the evidence is clear: unattended or non-skilled deliveries are strongly associated with preventable maternal and newborn deaths. On the other hand, blanket ordinances that penalize or criminalize home births may disproportionately burden poor and remote women who have limited real choice and may lack access to culturally-respectful, affordable facility care. Some communities also have strong cultural traditions around home birth (e.g., placenta burial practices, family presence, spiritual practices) that are not inherently unsafe if the birth is attended by a skilled provider. The professionally sound position keeps both truths in view: advocate facility-based skilled-attendant delivery as the safe default, but acknowledge the barriers that prevent access, work to remove them, and respect cultural practices that do not compromise safety. The midwife's role is to be an educator and enabler, not a punitive authority. Building trust and making safe care accessible is more effective—and more ethical—than coercion.

Because the hilot is community-trusted but cannot manage obstetric complications (and leading causes of maternal death are unpredictable and rapidly fatal), DOH policy shifted from endorsing TBA-attended home births to mandating facility-based delivery by a skilled birth attendant. The TBA's cultural reach is valuable, but her lack of formal training is a safety liability that cannot be overcome by experience alone.

A skilled birth attendant can recognize danger signs, administer first-line interventions (oxytocics, magnesium sulphate, antibiotics), and communicate urgently with a receiving facility—actions that can be lifesaving within the critical window of minutes. Because these competencies are only reliably available in facilities and in trained providers, facility-based, skilled-attendant delivery becomes the evidence-based standard.

The policy order that mandates facility-based delivery by an SBA explicitly redefines the TBA away from conducting deliveries toward case-finding, motivation, referral, and accompaniment. The redefinition is not punitive; it is an integration strategy that leverages the TBA's community trust for a safer purpose: funneling women into skilled care.

The tiered network of BEmONC and CEmONC facilities provides the destination and infrastructure for the midwife's referral pathway. The midwife must know the capabilities of facilities in her catchment and match the complexity of the case to the appropriate level of care. The network only functions if midwives (and TBAs) understand and use it.

The midwife's training, orientation, and collaboration with the TBA determines whether the TBA becomes a safe, effective referral partner or remains outside the system. A well-supervised, respected TBA embedded in the community MCH team enhances case-finding and referral uptake. A neglected or antagonized hilot may resist or undermine facility-based delivery.

A two-way, documented, timely referral system ensures that pregnant women are identified early, referred to prenatal care, delivered in a facility, and escalated to emergency care if needed, with feedback ensuring the TBA and community remain engaged. A broken referral chain—delayed communication, missing feedback, lack of trust—means that women fall out of skilled care at critical points, leading to preventable deaths.

The midwife's advocacy for facility-based delivery must be grounded in understanding the actual barriers her community faces: cost (lack of PhilHealth enrollment, clinic fees), distance (no transport, poor roads), time (work, farming), and cultural discomfort (facilities perceived as disrespectful or cold). Targeted enablement—linking to PhilHealth, organizing transport, making facilities welcoming—is more effective than generic messaging or coercion.

When the midwife and facility respect cultural practices (birth companions, modesty, dietary preferences, family involvement), and when the TBA is honored as a partner rather than dismissed as unsafe, community trust in the health system increases. Increased trust translates into higher prenatal care attendance, facility-delivery uptake, and post-delivery follow-up—all protective of maternal and newborn health.

Because life-threatening complications (PPH, eclampsia, obstructed labour, sepsis) can appear suddenly in a woman with no prior risk factors, and because the margin for rescue is minutes not hours, every birth must occur in or very near a facility equipped for emergency obstetric care. This clinical reality, not arbitrary policy, is why even low-risk deliveries are facility-based.

The legal prohibition against demanding payment before emergency care ensures that a midwife and TBA can safely refer an acutely ill mother without fear that lack of immediate funds will delay life-saving intervention. This law operationalizes the referral pathway by removing a major barrier to timely transfer.