Midwife Licensure Exam Midwifery Pharmacology & Newborn Procedures — Maternal & Child Nutrition Counseling (Midwife-led)Summary

The DOH standard is 60 mg elemental iron + 400 micrograms (0.4 mg) folic acid once daily, started at the first prenatal visit and continued throughout pregnancy and for 3 months postpartum. Iron prevents and treats anemia, reducing the risk of preterm birth, low birth weight, and postpartum hemorrhage (PPH)-related death in Filipino women. Folic acid is most protective against neural tube defects (spina bifida, anencephaly) when taken before conception and in the first trimester. The midwife counsels that iron is absorbed best with vitamin-C-rich foods, on a relatively empty stomach, and that tea and coffee reduce absorption; black stools are a normal, expected side effect. For diagnosed anemia, the dose may be doubled to twice daily under protocol, and severe anemia requires referral to a physician.

High-dose Vitamin A (200,000 IU or higher) is teratogenic and must NEVER be given during pregnancy because it increases the risk of birth defects and fetal loss. The midwife must confirm a woman is not pregnant before giving any high-dose supplement. Postpartum, where DOH policy provides it, a mother receives 200,000 IU Vitamin A within the early postpartum period (typically within the first 4 weeks, while still amenorrheic and lactating) to rebuild her stores and enrich breast milk with Vitamin A. This is often timed with the postpartum visit or early home visit.

Vitamin A deficiency causes night blindness, xerophthalmia (corneal scarring), and increased susceptibility to infection and death in young children — it is a pillar of child-survival programs. The DOH schedule is: (1) Infants 6–11 months: 100,000 IU single dose; (2) Children 12–59 months (1–5 years): 200,000 IU every 6 months (typically timed with the biannual 'Garantisadong Pambata' rounds). Vitamin A is not routinely given below 6 months to breastfed infants because they receive adequate amounts from breast milk, especially if the mother received her postpartum dose. High-dose Vitamin A is also given as an adjunct in measles and severe illness per protocol. The midwife records each dose to avoid over-dosing, since Vitamin A is fat-soluble and accumulates.

RA 10028 (Expanded Breastfeeding Promotion Act of 2009), building on EO 51 (the Milk Code) and RA 7600 (Rooming-In and Breastfeeding Act), mandates the promotion, protection, and support of breastfeeding. The WHO/DOH recommendation is: (1) Initiate breastfeeding within the first hour of life (part of EINC/Unang Yakap); (2) Exclusive breastfeeding for the first 6 months — breast milk only, no water, no other food or drink, not even small amounts of water in a hot climate; (3) Continue breastfeeding up to 2 years and beyond with appropriate complementary foods. Colostrum (the first thick, yellowish milk) is rich in antibodies and must never be discarded. The Milk Code prohibits advertising and promotion of breast-milk substitutes, feeding bottles, and teats, and forbids health workers from accepting or distributing formula samples. RA 10028 requires lactation stations in workplaces and public places and guarantees lactation breaks for working mothers. Benefits include ideal nutrition, immune protection, bonding, and LAM (Lactational Amenorrhea Method) contraceptive effect when the baby is under 6 months, exclusively breastfed, and menses have not returned.

Good positioning and latch prevent sore and cracked nipples and ensure the baby obtains enough milk. The midwife teaches the 'four keys to good positioning': (1) baby's head and body in a straight line (not twisted); (2) baby held close to the mother; (3) baby's whole body supported (not just the head); (4) baby facing the breast, nose to nipple. Signs of a good latch (attachment) include: (1) more areola visible above the mouth than below; (2) mouth wide open; (3) lower lip turned outward (everted); (4) chin touching the breast. During feeding, a good latch produces slow, deep sucks with pauses and audible or visible swallowing. The baby self-releases when satisfied. The midwife reassures the mother that feeding on demand, 8–12 times per 24 hours, and the presence of 6 or more wet diapers per day indicate sufficient milk intake and adequate feeding.

Most breastfeeding 'failures' are actually technique problems, not milk-supply problems. (1) Sore/cracked nipples are almost always caused by poor attachment; the solution is to correct the latch, keep nipples dry, and apply a little hindmilk to the nipple for healing. (2) 'Not enough milk' perception — reassure the mother that supply follows demand; advise more frequent feeding, use of both breasts, night feeds, and ensuring the baby finishes the fat-rich hindmilk on one side before switching. Genuine milk insufficiency is rare and is shown by poor weight gain and few wet diapers. (3) Engorgement — manage with frequent feeding, expressing a little milk to soften the areola for latching, and applying warm compresses before feeding and cold compresses after. (4) Working mothers — teach safe expression and storage of breast milk and cite workplace lactation breaks and lactation stations under RA 10028 to sustain exclusive breastfeeding. The midwife also counsels that the mother's own nutrition and hydration support lactation (an extra ~500 kcal/day and plenty of fluids), but that even a modestly nourished mother produces adequate milk.

At 6 completed months, breast milk alone no longer meets energy and micronutrient needs, so complementary foods are introduced while breastfeeding continues. The four principles are: timely, adequate, safe, and responsively fed. (1) Start at 6 months with soft, mashed, energy-dense foods; introduce one new food at a time to watch for allergies. (2) Increase frequency and variety with age: roughly 2–3 meals per day at 6–8 months, 3–4 meals per day at 9–23 months, plus 1–2 nutritious snacks from about 12 months. Gradually shift from purees to thicker, family foods. (3) Include iron-rich and animal-source foods (egg, fish, meat, liver) plus fruits and vegetables and a little added fat/oil for energy density. (4) Practice responsive feeding (feed based on hunger and satiety cues, not forcing) and strict food hygiene to prevent diarrhea. Avoid feeding bottles (aligns with the Milk Code), sugary drinks, tea, and low-nutrient 'junk' food. The midwife uses simple language appropriate to the mother's literacy and cultural context.

Growth Monitoring and Promotion is a routine midwife-led activity, typically conducted monthly for infants and at each child visit at the BHS or during home visits. The process involves: (1) weighing the child; (2) plotting weight (and where possible length/height) on the Growth Monitoring Chart or ECCD/WHO Child Growth Standards card in the mother-child book (Maternal-Child Health Record); (3) interpreting the direction of the growth curve — a flat or falling line signals a problem earlier than a single low weight does; (4) classifying nutritional status (normal, underweight, severely underweight; and by MUAC or edema for acute malnutrition); (5) providing feeding advice; (6) delivering Vitamin A and deworming per schedule; (7) checking immunization status; (8) referring faltering or severely malnourished children to a physician or therapeutic program. Severe acute malnutrition is indicated by MUAC < 11.5 cm in a child 6–59 months, bilateral pedal edema (kwashiorkor), or marasmus (severe wasting). Each weighing is a teaching moment with the mother to discuss feeding and health.

The ASIN Law (RA 8172) mandates iodized salt to prevent iodine-deficiency disorders and goiter. The midwife promotes the use of iodized salt in household cooking and counseling. Adequate calcium intake is also important in pregnancy and lactation; calcium supplementation is used in some protocols to reduce pre-eclampsia risk in low-intake populations. The midwife counsels on dietary sources of calcium (dairy, leafy greens, small fish with bones) and coordinates any supplementation per local protocol.

Intestinal worm infection worsens anemia and undernutrition, reducing micronutrient absorption and contributing to poor growth. Under DOH policy, the midwife supports twice-yearly deworming of children (commonly albendazole 400 mg; children 12–23 months receive 200 mg). Deworming is typically timed with the Vitamin A rounds for convenience. Pregnant women may be dewormed after the first trimester per protocol (after organogenesis is complete) to reduce anemia. The midwife educates mothers on food hygiene and sanitation to reduce reinfection.

The Food Fortification Law (RA 8976) and related programs support fortification of staple foods — iron-fortified rice, iodized salt, and fortified cooking oil — to address population-level micronutrient deficiencies without relying on supplements alone. The midwife promotes the use of fortified foods in household preparation and links families to community feeding programs for the malnourished (e.g., supplementary feeding programs for underweight children, school feeding). These efforts are part of the comprehensive nutrition landscape at the BHS.

The iron-folate supplement (60 mg + 400 mcg) works through two pathways: iron increases hemoglobin and reduces the risk of severe anemia, PPH, and preterm birth; folic acid reduces the risk of neural tube defects (spina bifida, anencephaly) if taken before conception and in the first trimester. Both are essential for healthy pregnancy outcomes.

When a postpartum mother receives high-dose Vitamin A (200,000 IU), her breast milk becomes enriched with Vitamin A, protecting her exclusively breastfed infant (below 6 months) from deficiency. This eliminates the need for direct infant supplementation below 6 months and demonstrates the mother-infant nutritional link.

These three stages form a continuum: exclusive breastfeeding provides optimal nutrition and immunity for the first 6 months; at 6 months, complementary foods are introduced while breastfeeding continues because breast milk alone is no longer sufficient; breastfeeding continues alongside family foods until 2 years and beyond for continued immunological, nutritional, and emotional benefits.

Correct latch and positioning ensure that the baby efficiently transfers milk, feeds to satisfaction, and gains weight appropriately. Poor latch leads to maternal pain, perceived insufficient milk, and infant underfed — early recognition and correction of latch problems is the midwife's frontline intervention.

When complementary foods are timely (from 6 months), adequate (frequent, energy-dense, iron-rich, including animal-source foods), and safely prepared, the child maintains the growth velocity achieved during exclusive breastfeeding and continues to develop optimally. Poor-quality complementary feeding leads to growth faltering.

Regular growth monitoring acts as an early-warning system: the growth curve reveals faltering before the child becomes severely malnourished. Early detection triggers nutritional counsel, investigation of feeding practices, and timely referral, preventing progression to severe malnutrition and death.

These three approaches work synergistically: deworming reduces parasitic loss of nutrients and improves absorption; supplementation (iron, Vitamin A, folate) directly provides essential nutrients; food fortification ensures population-level access. Together, they comprehensively address nutritional deficiencies.

The legal framework protects breastfeeding by mandating workplace support, prohibiting formula promotion, and guaranteeing lactation rights. The midwife's role is to counsel mothers on these rights, support early initiation and exclusive feeding, and advocate for the policy implementation in the community.

Good maternal nutrition during pregnancy ensures adequate fetal development, reduces the risk of preterm birth and low birth weight, and provides the maternal micronutrient stores (especially iron and Vitamin A) that support early breastfeeding and infant health.

RA 10028 mandates workplace support; the midwife teaches expression and storage of breast milk; combined with workplace lactation facilities, working mothers can sustain exclusive breastfeeding even after returning to employment, extending the period of direct infant protection.